经动脉化疗栓塞治疗：多次治疗、累计支出与生存的关系。
Transarterial chemoembolization treatment: association between multiple treatments, cumulative expenditures, and survival.
机构信息
Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
出版信息
Value Health. 2013 Jul-Aug;16(5):760-8. doi: 10.1016/j.jval.2013.03.1630. Epub 2013 May 28.
OBJECTIVES
To examine cumulative survival and Medicaid-paid expenses associated with multiple courses of transarterial chemoembolization (TACE) as primary treatment for hepatocellular carcinoma (HCC).
METHODS
Medicare enrollees diagnosed with primary HCC from 2000 to 2007, ever treated with TACE, but not transplant/resection, followed through 2009 by using the Surveillance, Epidemiology and End-Results Program and linked Medicare databases. Cumulative all-cause/HCC-related survival was estimated by using multivariate Cox proportional hazards models stratified by the total number of TACE treatments. Multivariate weighted Cox regressions estimated the average risk of mortality faced with nonproportional hazards. Lin's inverse probability-weighted least squares regression method estimated cumulative Medicare expenditures adjusted for censoring and covariates.
RESULTS
Of 1228 patients, 34% were stage 1, 16% stage 2, 19% stage 3, 6% stage 4, and 26% unstaged. About 44% were aged 65 to 75 years, 69% were men, and 72% were Caucasian. Over half (57%) of the patients received one course, 24% two, 11% three, and 8% four courses of TACE. One-course patients incurred an average $74,788 (95% confidence interval [CI] $71,890-$77,686), two-course patients $101,126 (95% CI $94,395-$107,856), three-course patients $111,776 (95% CI $101,931-$121,621), and four-plus-course patients $148,878 (95% CI $136,346-$161,409). One-course patients lived (all-cause) an average 1.86 (95% CI 1.82-1.90), two-course patients 2.09 (95% CI 2.05-2.13), three-course patients 2.81 (95% CI 2.66-2.97), and four-plus-course patients 3.06 (95% CI 2.95-3.18) years after diagnosis. Average risk of all-cause mortality was not significantly different between one/two courses or three/four-plus courses.
CONCLUSIONS
Cumulative Medicare expenditures nearly doubled from one-course to four-plus-course patients. On average, four-plus-course patients lived over one more year than did one-course patients. Physician/patient decisions should be balanced with consideration of efficient use of limited resources, but payer's intervention in physician discretion may not be important in this setting.
目的
研究多次经动脉化疗栓塞（TACE）作为原发性肝细胞癌（HCC）的主要治疗方法与累积生存率和医疗补助支出的相关性。
方法
从 2000 年至 2007 年，选择接受过 TACE 治疗但未接受过移植/切除术治疗的 Medicare 参保者作为原发性 HCC 患者，通过监测、流行病学和最终结果计划以及相关的 Medicare 数据库进行随访，直至 2009 年。采用多变量 Cox 比例风险模型对 TACE 治疗总数分层，估计全因/HCC 相关生存率。采用多变量加权 Cox 回归估计非比例风险下的平均死亡风险。采用 Lin 逆概率加权最小二乘法回归方法估计调整了截尾和协变量的累积医疗保险支出。
结果
在 1228 例患者中，34%为Ⅰ期，16%为Ⅱ期，19%为Ⅲ期，6%为Ⅳ期，26%为未分期。约 44%的患者年龄在 65 至 75 岁之间，69%为男性，72%为白种人。超过一半（57%）的患者接受了一次 TACE 治疗，24%接受了两次，11%接受了三次，8%接受了四次。一次 TACE 治疗的患者平均支出为 74788 美元（95%置信区间[CI]：71890 美元至 77686 美元），两次 TACE 治疗的患者平均支出为 101126 美元（95%CI：94395 美元至 107856 美元），三次 TACE 治疗的患者平均支出为 111776 美元（95%CI：101931 美元至 121621 美元），四次及以上 TACE 治疗的患者平均支出为 148878 美元（95%CI：136346 美元至 161409 美元）。一次 TACE 治疗的患者（全因）平均存活 1.86 年（95%CI：1.82 年至 1.90 年），两次 TACE 治疗的患者存活 2.09 年（95%CI：2.05 年至 2.13 年），三次 TACE 治疗的患者存活 2.81 年（95%CI：2.66 年至 2.97 年），四次及以上 TACE 治疗的患者存活 3.06 年（95%CI：2.95 年至 3.18 年）。一次/TACE 治疗和三次/四次及以上 TACE 治疗之间的全因死亡率平均风险没有显著差异。
结论
从一次 TACE 治疗到四次及以上 TACE 治疗，医疗保险支出几乎翻了一番。平均而言，四次及以上 TACE 治疗的患者比一次 TACE 治疗的患者多活一年以上。在这种情况下，医生/患者的决策应该在考虑有效利用有限资源的基础上进行平衡，但支付方对医生自主权的干预可能并不重要。
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