CAPHRI, School for Public Health and Primary Care, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands.
MHeNS, School for Mental Health and Neuroscience; Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences Maastricht University, P.O. Box 616, 6200 MD, Maastricht, the Netherlands.
BMC Health Serv Res. 2020 Apr 8;20(1):294. doi: 10.1186/s12913-020-05103-x.
Since stroke survivors are increasingly responsible for managing stroke-related changes in their own health and lifestyle, self-management skills are required. In a recent randomised controlled trial a self-management intervention based on proactive coping action planning (SMI) in comparison with an education-based intervention (EDU) in stroke patients was investigated. However, no relevant treatment effects on the Utrecht Proactive Coping Competence scale (UPCC) and the Utrecht Scale for Evaluation of Rehabilitation Participation (USER-Participation) were found. The current study is a trial-based economic evaluation from a societal perspective comparing the same interventions (SMI versus EDU).
UPCC, USER-Participation and EuroQol (EQ-5D-3 L) and costs were measured at baseline, three, six and twelve months after treatment. For the cost-effectiveness analyses, incremental cost effectiveness ratios (ICERs) were calculated for UPCC and USER-Participation. For the cost-utility analyses the incremental cost utility ratio (ICUR) was expressed in cost per Quality Adjusted Life Years (QALYs). Outcomes were tested by means of AN(C)OVA analyses and costs differences by means of bootstrapping. Bootstrapping, sensitivity analyses and a subgroup analysis were performed to test the robustness of the findings.
One hundred thirteen stroke patients were included in this study. The mean differences in USER-Participation scores (95%CI:-13.08,-1.61, p-value = .013) were significant different between the two groups, this does not account for UPCC scores (95%CI:-.267, .113, p-value = not significant) and QALYs (p-value = not significant) at 12 months. The average total societal costs were not significantly different (95%CI:€-3380,€7099) for SMI (€17,333) in comparison with EDU (€15,520). Cost-effectiveness analyses showed a mean ICER of 26,514 for the UPCC and 346 for the USER-Participation. Cost-utility analysis resulted in an ICUR of €44,688 per QALY. Assuming a willingness to pay (WTP) threshold of €50,000 per QALY, the probability that SMI will be cost-effective is 52%. Sensitivity analyses and subgroup analysis showed the robustness of the results.
SMI is probably not a cost-effective alternative in comparison with EDU. Based on the current results, the value of implementing SMI for a stroke population is debatable. We recommend further exploration of the potential cost-effectiveness of stroke-specific self-management interventions focusing on different underlying mechanisms and using different control treatments.
由于中风幸存者越来越需要管理与中风相关的健康和生活方式变化，因此需要自我管理技能。在最近的一项随机对照试验中，研究了一种基于主动应对行动计划的自我管理干预（SMI）与基于教育的干预（EDU）在中风患者中的效果。然而，在乌得勒支积极应对能力量表（UPCC）和乌得勒支康复参与评估量表（USER-Participation）上没有发现相关的治疗效果。目前的研究是一项基于试验的经济评估，从社会角度比较了相同的干预措施（SMI 与 EDU）。
在治疗后 3、6 和 12 个月，分别测量 UPCC、USER-Participation、EuroQol（EQ-5D-3L）和成本。对于成本效果分析，计算了 UPCC 和 USER-Participation 的增量成本效果比（ICER）。对于成本效用分析，增量成本效用比（ICUR）表示为每质量调整生命年（QALYs）的成本。采用 AN(C)OVA 分析检验结果，采用 bootstrap 检验成本差异。进行 bootstrap 分析、敏感性分析和亚组分析以检验结果的稳健性。
本研究共纳入 113 例中风患者。两组之间 USER-Participation 评分的平均差异（95%CI：-13.08，-1.61，p 值=0.013）具有统计学意义，但 UPCC 评分（95%CI：-.267，.113，p 值=无统计学意义）和 QALYs（p 值=无统计学意义）在 12 个月时无差异。SMI（€17333）与 EDU（€15520）相比，平均总社会成本无显著差异（95%CI：€-3380，€7099）。成本效果分析显示，UPCC 的平均 ICER 为 26514，USER-Participation 的平均 ICER 为 346。成本效用分析得出每 QALY 的 ICUR 为€44688。假设每 QALY 50000 欧元的意愿支付（WTP）阈值，SMI 具有成本效益的概率为 52%。敏感性分析和亚组分析表明结果具有稳健性。
与 EDU 相比，SMI 可能不是一种具有成本效益的替代方法。基于目前的结果，实施针对中风人群的 SMI 的价值值得商榷。我们建议进一步探索针对不同潜在机制和使用不同对照治疗的中风特定自我管理干预的潜在成本效益。
