Taleban Sasha, Van Oijen Martijn G H, Vasiliauskas Eric A, Fleshner Phillip R, Shen Bo, Ippoliti Andrew F, Targan Stephan R, Melmed Gil Y
F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA.
Division of Gastroenterology, Department of Medicine, University of Arizona Medical Center, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA.
Dig Dis Sci. 2016 Feb;61(2):550-9. doi: 10.1007/s10620-015-3886-3. Epub 2015 Oct 5.
Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients.
We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD.
We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness.
IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy.
In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.
克罗恩病（CD）的许多经济负担与手术相关。20%的CD患者患有孤立性结肠疾病。虽然永久性末端回肠造口术（EI）通常是难治性CD结肠炎患者的首选手术方式，但单中心经验表明，在特定患者中，全结肠直肠切除术（IPAA）效果持久。
我们评估了在药物难治性结肠CD患者中，永久性EI全结肠切除术与IPAA的成本效益。
我们使用了一个以6个月为周期的终身马尔可夫模型来模拟质量调整生命年（QALY）和成本。在EI和IPAA两种策略中，患者均可在多种健康状态之间转换。进行了单因素和多因素敏感性分析以及龙卷风分析，以确定影响成本效益的因素阈值。
IPAA比EI手术更有效，每获得一个QALY的增量成本效益比为70,715美元。我们在模型中确定了以下重要变量：（1）EI手术成本，（2）英夫利昔单抗成本，（3）胃肠病门诊就诊和实验室检查成本。阈值分析显示，如果与EI手术相关的成本超过20,167美元，或者未经药物治疗的IPAA伴CD缓解的效用超过0.37，则IPAA成为更具成本效益的策略。
在孤立性结肠药物难治性CD患者中，永久性EI全结肠切除术比IPAA更具成本效益，除非与EI手术相关的成本超过20,167美元，或者与IPAA和CD缓解相关的效用超过0.37。
