Pershad Jay, Waters Teresa M, Langham Max R, Li Tao, Huang Eunice Y
Department of Emergency Medicine, University of Tennessee Health Science Center, Memphis, TN.
Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN.
J Am Coll Surg. 2015 Apr;220(4):738-46. doi: 10.1016/j.jamcollsurg.2014.12.019. Epub 2014 Dec 20.
Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care.
We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters.
In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio.
Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.
我们团队最近发布了一种临床路径（勒邦赫临床路径[LeB-P]），该路径使用塞缪尔小儿阑尾炎评分并选择性地使用超声检查（USG）来诊断有阑尾炎风险的儿童。本研究的目的是模拟实施LeB-P与常规护理相比的成本效益。
我们构建了一个决策分析模型，比较了以下疑似阑尾炎诊断策略的医院成本：仅由急诊科医生判断、对所有患者进行USG检查、对所有患者进行CT检查、不进行检查的过夜观察并进行手术评估，以及LeB-P。每种方案的疾病患病率、结果概率以及医院和专业成本均来自已发表的文献、国家成本数据以及我们之前的研究结果。使用这三组参数计算成本效益。
在基础病例模型中，USG是比LeB-P以及不进行检查的过夜观察并进行手术评估更优的策略。仅由急诊科医生判断和CT检查在诊断准确性较低或成本增加方面被其他路径所主导。与LeB-P相比，对每位接受评估的患者，USG成本少337美元，但诊断错误率增加了2%。使用LeB-P而非USG将使机构额外花费17,206美元来消除一次误诊，这就是所谓的增量成本效益比。
尽管对所有疑似阑尾炎儿童进行USG检查被确定为最具成本效益的策略，但使用小儿阑尾炎评分并选择性地使用USG（LeB-P）在成本适度增加的情况下提高了诊断准确性，并减少了CT的使用。
