Berman S, Roark R, Luckey D
Department of Pediatrics, University of Colorado School of Medicine, Denver.
Pediatrics. 1994 Mar;93(3):353-63.
The purpose of this theoretical study is to assess the cost effectiveness of options involving observation, antibiotics alone, corticosteroids alone, corticosteroids plus antibiotics, and surgery to clear persisting middle ear effusions during three visits.
In a hypothetical case the expected average per patient expenditures are calculated using the efficacy rates determined by the meta-analysis of randomized controlled clinical trials involving corticosteroids plus an antibiotic (six trials), corticosteroids alone (three trials), and antibiotic alone (four trials). In this analysis, all children whose bilateral middle ear effusions persist for 12 weeks despite medical management are referred for ventilating tubes.
The most cost-effective intervention combination is corticosteroid plus an antibiotic at visit 1 (6 weeks after diagnosis of acute otitis media) followed by a second antibiotic in nonresponders at visit 2 (9 weeks after diagnosis of acute otitis media) and referral for ventilating tubes in nonresponders at visit 3 (12 weeks after diagnosis of acute otitis media). The expected average expenditures per case to clear the bilateral middle ear effusions is $600.91 based on reimbursement of private practice charges and $350.27 based on Medicaid reimbursement (all payments to providers are based on 1992 data from Colorado). The difference in the expected average total expenditures per case between this most cost-effective approach versus the use of sequential courses of antibiotics followed by surgery is $372.81 ($973.72-$600.91) with full reimbursement of private practice charges and $202.57 ($552.84-$350.27) with Medicaid reimbursement. In clearing the middle ear effusion, the average estimated travel expenses per case is $21.46, and lost parental wages per case are $45.12. When the expenditures associated with an additional 6-month follow-up period are included, the expected average per case expenditures is $1088.54 with reimbursement of private practice charges and @659.00 with Medicaid reimbursement. The difference in the expected average per case expenditures to clear the effusions and follow-up for 6 months between the most cost-effective approach using corticosteroids plus antibiotics at the 6- and 9-week visits followed by surgery in nonresponders at 12 weeks versus sequential courses of antibiotics is $405.30 ($1493.84-$1088.54) with reimbursement of private practice charges and $217.32 ($876.32-$659.00) with Medicaid reimbursement.
Although the analysis does not consider risks, side effects, and parental or provider preferences, the findings suggest that the implementation of cost-effective clinical guidelines can potentially reduce national expenditures for managing persistent middle ear effusions.
本理论研究旨在评估在三次就诊期间，采用观察、单独使用抗生素、单独使用皮质类固醇、皮质类固醇加抗生素以及手术清除持续性中耳积液等方案的成本效益。
在一个假设案例中，使用对涉及皮质类固醇加抗生素（六项试验）、单独使用皮质类固醇（三项试验）以及单独使用抗生素（四项试验）的随机对照临床试验进行荟萃分析所确定的有效率，计算每位患者的预期平均支出。在该分析中，所有尽管经过药物治疗但双侧中耳积液仍持续12周的儿童均被转诊进行置管。
最具成本效益的干预组合是在第1次就诊（急性中耳炎诊断后6周）使用皮质类固醇加抗生素，然后在第2次就诊（急性中耳炎诊断后9周）对无反应者使用第二种抗生素，在第3次就诊（急性中耳炎诊断后12周）对无反应者转诊进行置管。根据私人执业费用报销情况，清除双侧中耳积液的每例预期平均支出为600.91美元；根据医疗补助报销情况为350.27美元（所有向提供者的支付均基于1992年科罗拉多州的数据）。这种最具成本效益的方法与依次使用抗生素疗程然后进行手术相比，每例预期平均总支出的差异为372.81美元（973.72美元 - 600.91美元），按私人执业费用全额报销；差异为202.57美元（552.84美元 - 350.27美元），按医疗补助报销。在清除中耳积液方面，每例平均估计交通费用为21.46美元，每例父母误工工资为45.12美元。当纳入与额外6个月随访期相关的支出时，按私人执业费用报销的每例预期平均支出为1088.54美元，按医疗补助报销为659.00美元。在第6周和第9周就诊时使用皮质类固醇加抗生素，然后在第12周对无反应者进行手术的最具成本效益的方法与依次使用抗生素疗程相比，清除积液并随访6个月的每例预期平均支出差异为405.30美元（1493.84美元 - 1088.54美元），按私人执业费用报销；差异为217.32美元（876.32美元 - 659.00美元），按医疗补助报销。
尽管该分析未考虑风险、副作用以及父母或提供者的偏好，但研究结果表明，实施具有成本效益的临床指南可能会降低国家用于管理持续性中耳积液的支出。
