Oudkerk M, van Beek E J, van Putten W L, Büller H R
Department of Radiodiagnostics, Dr Daniël den Hoed Cancer Center, Rotterdam, The Netherlands.
Arch Intern Med. 1993 Apr 26;153(8):947-54.
Since the clinical diagnosis of pulmonary embolism is unreliable, various objective diagnostic methods (or combinations thereof) are advocated. Pulmonary angiography is the accepted reference method but is considered less suitable for initial screening due to its invasive nature. Therefore, at least nine different diagnostic management strategies employing invasive and noninvasive diagnostic tests are used in clinical practice. We assessed the cost-effectiveness of these strategies to help identify the optimal approach.
Based on assumptions derived from published data, we calculated mortality, morbidity, adequacy for the indication of anticoagulant therapy, and associated diagnostic and therapeutic costs using a decision analytic model. Additionally, a cost-effectiveness analysis was performed using incremental costs per additional life saved.
The analysis identified three separate categories of diagnostic management strategies: (1) Treatment of all patients (or of those with an abnormal perfusion scan) results in the lowest mortality and morbidity rates but the highest costs due to inappropriate treatment of 55% to 70% of patients. (2) Pulmonary angiography strategies with or without prior perfusion-ventilation lung scintigraphy and ultrasonography of the legs have comparable low mortality and morbidity rates, costs savings of approximately 40%, and inappropriate treatment in fewer than 5% of patients. (3) Use of perfusion-ventilation scintigraphy with or without ultrasonography results in unacceptably high mortality rates.
At present, the optimal diagnostic management strategy should include pulmonary angiography. Use of perfusion-ventilation lung scintigraphy and ultrasonography results in a 40% to 50% reduction in the number of patients requiring pulmonary angiography and is cost-effective.
由于肺栓塞的临床诊断不可靠，因此提倡采用各种客观诊断方法（或其组合）。肺血管造影是公认的参考方法，但由于其侵入性，被认为不太适合用于初始筛查。因此，临床实践中使用了至少九种采用侵入性和非侵入性诊断测试的不同诊断管理策略。我们评估了这些策略的成本效益，以帮助确定最佳方法。
基于已发表数据得出的假设，我们使用决策分析模型计算了死亡率、发病率、抗凝治疗指征的充分性以及相关的诊断和治疗成本。此外，还使用每多挽救一条生命的增量成本进行了成本效益分析。
分析确定了三类不同的诊断管理策略：（1）对所有患者（或灌注扫描异常的患者）进行治疗，死亡率和发病率最低，但由于55%至70%的患者治疗不当，成本最高。（2）无论是否进行过灌注-通气肺闪烁扫描和腿部超声检查的肺血管造影策略，死亡率和发病率都相当低，成本节省约40%，且不到5%的患者治疗不当。（3）使用灌注-通气闪烁扫描（无论是否进行超声检查）导致死亡率高得令人无法接受。
目前，最佳诊断管理策略应包括肺血管造影。使用灌注-通气肺闪烁扫描和超声检查可使需要进行肺血管造影的患者数量减少40%至50%，且具有成本效益。
