Michel B C, Seerden R J, Rutten F F, Van Beek E J, Büller H R
Institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands.
Health Econ. 1996 Jul-Aug;5(4):307-18. doi: 10.1002/(SICI)1099-1050(199607)5:4<307::AID-HEC214>3.0.CO;2-4.
The cost-effectiveness of various diagnostic strategies in patients with clinically suspected pulmonary embolism (PE) was analysed using a modelling approach. In 451 consecutive patients with clinically suspected PE data on the performance of diagnostic tests were collected prospectively in two large teaching hospitals in Amsterdam, The Netherlands. The ventilation-perfusion lung scan was used as the primary diagnostic test in all patients. In patients with a non-diagnostic lung scan result the performance of a clinical decision rule, a D-dimer test, and ultrasonography of the leg veins was evaluated with pulmonary angiography as the gold standard. It was estimated that the strategy recommended by a 1992 Dutch consensus meeting costs about Dfl 4400 per patient and that 97.02% of the patients can be expected to survive the first 6 months after the primary PE. The nation-wide annual costs for the diagnosis and treatment of patients by this strategy were estimated at 163 million Dutch Guilders. Subsequently, the costs and effects of alternative strategies were evaluated in a modelling approach, and compared with those of the consensus strategy. One strategy was selected that produces the best results in terms of survival and leads to considerable savings as compared with the consensus strategy. In this strategy subsequently a ventilation-perfusion scan, a clinical decision rule, a D-dimer test, a pulmonary angiography and leg ultrasonography are performed. Patients with a high probability ventilation-perfusion scan, an abnormal angiography or leg ultrasound test are treated, whereas treatment is withheld in patients with a normal ventilation-perfusion scan, a normal clinical decision rule, a negative D-dimer test, a normal angiography, or a normal leg ultrasound test. This strategy will have to prove its value and usefulness in clinical practice in a subsequent prospective validation phase.
采用建模方法分析了临床疑似肺栓塞（PE）患者中各种诊断策略的成本效益。在荷兰阿姆斯特丹的两家大型教学医院，前瞻性收集了451例临床疑似PE患者的诊断试验性能数据。所有患者均以通气-灌注肺扫描作为主要诊断试验。对于肺扫描结果未明确诊断的患者，以肺血管造影作为金标准，评估临床决策规则、D-二聚体试验和腿部静脉超声检查的性能。据估计，1992年荷兰共识会议推荐的策略每位患者花费约4400荷兰盾，预计97.02%的患者在首次发生PE后的前6个月能够存活。采用该策略对患者进行诊断和治疗的全国年度成本估计为1.63亿荷兰盾。随后，采用建模方法评估了替代策略的成本和效果，并与共识策略进行了比较。选择了一种在生存方面产生最佳结果且与共识策略相比能节省大量费用的策略。在该策略中，随后进行通气-灌注扫描、临床决策规则、D-二聚体试验、肺血管造影和腿部超声检查。通气-灌注扫描高度可疑、血管造影异常或腿部超声检查异常的患者接受治疗，而通气-灌注扫描正常、临床决策规则正常、D-二聚体试验阴性、血管造影正常或腿部超声检查正常的患者则不进行治疗。在随后的前瞻性验证阶段，该策略必须在临床实践中证明其价值和实用性。
