膀胱过度活动症中骶神经调节的经济学评估：加拿大视角
Economic evaluation of sacral neuromodulation in overactive bladder: A Canadian perspective.
作者信息
Hassouna Magdy M, Sadri Hamid
机构信息
Division of Urology, University of Toronto, Toronto, ON;
Director Health Economics and HTA, Medtronic of Canada, Toronto, ON.
出版信息
Can Urol Assoc J. 2015 Jul-Aug;9(7-8):242-7. doi: 10.5489/cuaj.2711.
INTRODUCTION
Refractory overactive bladder (OAB) with urge incontinence is an underdiagnosed condition with substantial burden on the healthcare system and diminished patient's quality-of-life. Many patients will fail conservative treatment with optimized medical-therapy (OMT) and may benefit from minimally invasive procedures, including sacral-neuromodulation (SNM) or botulinum-toxin (BonT-A). The goal of this study was to estimate the cost-efectiveness of SNM vs. OMT and BonT-A as important parameters from coverage and access to a therapy.
METHODS
A Markov model with Monte-Carlo simulation was used to assess the incremental cost effectiveness ratio (ICER) of SNM vs. BonT-A and OMT both in deterministic and probabilistic analysis from a provincial payer perspective over a 10-year time horizon with 9-month Markov-cycles. Clinical data, healthcare resource utilization, and utility scores were acquired from recent publications and an expert panel of 7 surgeons. Cost data (2014-Dollars) were derived from provincial health insurance policy, drug benefit formulary, and hospital data. All cost and outcomes were discounted at a 3% rate.
RESULTS
The annual (year 1-10) incremental quality-adjusted life years for SNM vs. BonT-A was 0.05 to 0.51 and SNM vs. OMT was 0.19 to 1.76. The annual incremental cost of SNM vs. BonT-A was $7237 in year 1 and -$9402 in year 10 and was between $8878 and -$11 447 vs. OMT. In the base-case deterministic analysis, the ICER for SNM vs. BonT-A and OMT were within the acceptable range ($44 837 and $15 130, respectively) at the second year of therapy, and SNM was dominant in consequent years. In the base-case analysis the probability of ICER being below the acceptability curve (willingness-to-pay $50 000) was >99% for SNM vs. BonT-A at year 3 and >95% for OMT at year 2.
CONCLUSION
SNM is a cost-effective treatment option to manage patients with refractory OAB when compared to either BonT-A or OMT. From a Canadian payers' perspective, SNM may be considered a first-line treatment option in management of patients with OAB with superior long-term outcomes. Similar to all economic analysis, this study has limitations which are based on the assumptions of the used model.
引言
伴有急迫性尿失禁的难治性膀胱过度活动症（OAB）是一种诊断不足的疾病，给医疗系统带来沉重负担，降低了患者的生活质量。许多患者在接受优化药物治疗（OMT）的保守治疗时会失败，可能从包括骶神经调节（SNM）或肉毒杆菌毒素（BonT - A）在内的微创手术中获益。本研究的目的是评估SNM与OMT和BonT - A相比的成本效益，将其作为覆盖范围和治疗可及性的重要参数。
方法
采用带有蒙特卡洛模拟的马尔可夫模型，从省级支付方的角度，在10年时间范围内，以9个月的马尔可夫周期，评估SNM与BonT - A和OMT在确定性和概率性分析中的增量成本效益比（ICER）。临床数据、医疗资源利用和效用评分来自近期出版物以及由7名外科医生组成的专家小组。成本数据（2014年美元）来自省级医疗保险政策、药品福利处方集和医院数据。所有成本和结果均按3%的贴现率进行贴现。
结果
SNM与BonT - A相比，每年（第1 - 10年）的增量质量调整生命年为0.05至0.51；SNM与OMT相比为0.19至1.76。SNM与BonT - A相比，第1年的年度增量成本为7237美元，第10年为 - 9402美元；与OMT相比为8878美元至 - 11447美元。在基础案例确定性分析中，SNM与BonT - A和OMT的ICER在治疗第2年处于可接受范围内（分别为44837美元和15130美元），且在随后几年中SNM占主导地位。在基础案例分析中，第3年SNM与BonT - A相比，ICER低于可接受曲线（支付意愿为50000美元）的概率>99%；第2年OMT的该概率>95%。
结论
与BonT - A或OMT相比，SNM是治疗难治性OAB患者的一种具有成本效益的治疗选择。从加拿大支付方的角度来看，SNM可被视为治疗OAB患者的一线治疗选择且具有卓越的长期疗效。与所有经济分析一样，本研究存在基于所用模型假设的局限性。
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