Hunink M G, Bos J J
Department of Health Sciences, Faculty of Medicine, University of Groningen, The Netherlands.
AJR Am J Roentgenol. 1995 Jul;165(1):27-36. doi: 10.2214/ajr.165.1.7785625.
The purpose of this study was to evaluate the cost-effectiveness of dynamic chest CT, compared with plain chest radiography and immediate angiography, in deciding when angiography should be performed in hemodynamically stable patients with suspected aortic rupture after blunt chest trauma. The use of CT was evaluated in relation to the prior probability of aortic rupture.
A cost-effectiveness analysis comparing six diagnostic strategies combining chest radiography, CT, and angiography in various sequences was performed. Effectiveness was expressed as survival to hospital discharge, and costs were those incurred to society. Estimates for the variables in the analysis were derived from published reports. The model was evaluated for two cohorts of patients: those undergoing and those not undergoing CT for the evaluation of other injuries. Sensitivity analysis was performed for all variables in the model with emphasis on the prior probability of aortic rupture.
Selecting patients for triage to angiography based on the CT findings yielded higher effectiveness at a lower cost-effectiveness ratio than doing so based on the chest radiograph, and the incremental cost-effectiveness ratio was less than $500,000 per life saved. For the cohort undergoing CT for the evaluation of other injuries, triage to angiography based on the CT findings yielded equivalent survival chances compared with immediate angiography and cost less ($1468 per patient evaluated compared with $2508). For the cohort not undergoing CT for other injuries, immediate angiography yielded the highest survival chances but was expensive, with an incremental cost-effectiveness ratio of $2 million per life saved compared with triage based on CT. In the latter cohort, immediate angiography yielded higher survival chances and had a cost-effectiveness ratio of less than $500,000 compared with the triage by CT if the prior probability of aortic rupture was 5% or more.
Selecting hemodynamically stable patients after blunt chest trauma with suspected aortic rupture for angiography on the basis of CT findings is more effective than doing so based on the findings on chest radiography and is cost-effective compared with other accepted health care programs. Immediate angiography has a high incremental cost-effectiveness ratio compared with triage by CT and is warranted only in patients not undergoing CT for the evaluation of other injuries who have a prior probability of aortic rupture of 5% or more.
本研究旨在评估在钝性胸部创伤后疑似主动脉破裂的血流动力学稳定患者中，动态胸部CT与胸部X线平片及直接血管造影相比，在决定何时应进行血管造影方面的成本效益。根据主动脉破裂的先验概率对CT的使用进行了评估。
进行了一项成本效益分析，比较了六种以不同顺序组合胸部X线检查、CT和血管造影的诊断策略。有效性以出院生存率表示，成本为社会所承担的费用。分析中各变量的估计值来自已发表的报告。该模型针对两组患者进行了评估：一组是因评估其他损伤而接受CT检查的患者，另一组是未接受CT检查的患者。对模型中的所有变量进行了敏感性分析，重点是主动脉破裂的先验概率。
基于CT结果选择患者进行血管造影分流，与基于胸部X线片选择相比，在较低的成本效益比下具有更高的有效性，每挽救一条生命的增量成本效益比低于50万美元。对于因评估其他损伤而接受CT检查的队列，基于CT结果进行血管造影分流与直接血管造影相比，生存率相当，且成本更低（每位接受评估的患者为1468美元，而直接血管造影为2508美元）。对于未因其他损伤接受CT检查的队列，直接血管造影的生存率最高，但成本高昂，与基于CT的分流相比，每挽救一条生命的增量成本效益比为200万美元。在后者队列中，如果主动脉破裂的先验概率为5%或更高，与基于CT的分流相比，直接血管造影的生存率更高，且成本效益比低于50万美元。
根据CT结果选择钝性胸部创伤后疑似主动脉破裂的血流动力学稳定患者进行血管造影，比根据胸部X线检查结果选择更有效，与其他公认的医疗保健方案相比具有成本效益。与基于CT的分流相比，直接血管造影的增量成本效益比很高，仅适用于未因评估其他损伤而接受CT检查且主动脉破裂先验概率为5%或更高的患者。
