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内镜师指导下给予异丙酚与麻醉师协助下进行大肠癌筛查:一项成本效益分析

发布日期:2014-1-29 12:40:44 文章来源:ENDOSCOPY 作者次数:1228

    内镜师指导下给予异丙酚与麻醉师协助下进行大肠癌筛查:一项成本效益分析

    C. Hassan1, D. K. Rex2, G. S. Cooper3, R. Benamouzig4

    1意大利罗马Nuovo Regina Margherita 医院消化内科

    2美国印第安纳州印第安纳波利斯印第安纳大学医学中心胃肠病/肝病科

    3美国俄亥俄州克利夫兰大学医院案例医疗中心肠胃病科

    4法国巴黎Service de Gastroentérologie Hôpital Avicenne

    背景:在大多数情况下,在美国(US)和欧洲由麻醉医师或麻醉医师护士给予结肠镜检查所用的异丙酚。近来,已有人提议应在内镜师指导下由非麻醉师给予异丙酚(EDP),这样会潜在地节省了麻醉师报销成本。我们旨在评估筛查设置中的潜在的EDP相关的利益。

    方法:在马尔可夫模型中,我们对10万美国受试者的筛查和后续结肠镜检查总数进行了估计。采用EDP策略对麻醉师协助的结肠镜检查进行比较。模型结果针对50岁至80岁的美国人群,假定27%作为目前的结肠镜筛查纳入量。采用相应的列入美国政府医保(≥65岁)的平均报销费用和商业保险资料(50-64岁)估计麻醉师成本。按照医疗数据库,估计在麻醉师协助下的结肠镜检查比例。护士的平均薪水用于估计2周的EDP培训成本。按经过认证的胃肠病学家人数增加33%,估计美国内镜师的绝对人数。在参考情景中,未假定EDP死亡率,而且在敏感性分析时假定死亡率为0.0008 %。同时,采用美国人口普查数据。类似的结果也用于法国对欧洲国家中的EDP相关利益的评估。

    结果:对17166位护士(每位美国内镜师一位护士)进行EDP培训,结果显示花费4700万美元。在麻醉师协助下行结肠镜检查估计所需成本为95美元夫人医疗保险和450美元夫人非医疗商业保险,而且34.8%的结肠镜检查需要麻醉师协助。实施美国EDP方针可在10年节省32亿美元(Monte Carlo分析5-95%的百分数为27-119亿美元)。在敏感性分析中,假定50%的结肠镜检查是在麻醉师协助下实施的,结果显示有46亿美元的利益。假定死亡率为0.0008%,在每个获得的生命年中,麻醉师协助下的结肠镜检查比EDP方针增加了150万美元,这一结果支持了EDP作为最佳选择的这一观点。EDP相关的死亡率增加了31倍,或者在麻醉师协助下行结肠镜检查所致死亡率降低了17倍,这是EDP在该情况下不符合成本效益所需要的。在一项愈创木粪便潜血试验(g-FOBT)筛查计划中,法国实施EDP方针预计10年内可节省8亿欧元。

    结论:在筛查设置中实施EDP很可能具有可观的绝对经济利益,在美国10年内可节省32亿,在法国可节省8亿欧元。最终的EDP相关的死亡率对EDP成本效益的影响似乎是微乎其微的。在麻醉师协助下的结肠镜检查所需的巨大经济和医疗资源可更有效地用于其它临床领域。

     


     

    Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis

    C. Hassan1, D. K. Rex2, G. S. Cooper3, R. Benamouzig4

    1Gastroenterology Department; NuovoReginaMargheritaHospital,Rome,Italy

    2Division of Gastroenterology/Hepatology;IndianaUniversityMedicalCenter,Indianapolis,Indiana,USA

    3Division of Gastroenterology,UniversityHospitalsCaseMedicalCenter,Cleveland,Ohio;USA

    4Service de Gastroentérologie Hôpital Avicenne,Paris,France

    Background: Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) andEurope. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting.

    Methods: In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000USsubjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 - 80-year-oldUSpopulation, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code (≥ 65-year-olds) and from commercial insurance information (50 - 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used forFranceto assess EDP-related benefit in a European country.

    Results: EDP training for 17 166 nurses (one for eachUSendoscopist) showed a cost of $ 47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance.USimplementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carloanalysis 5 - 95 % percentiles $ 2.7 - $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost - effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy inFrance, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save € 0.8 billion in 10 years.

    Conclusions: The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in theUSand €0.8 billion inFrance. The impact of an eventual EDP-related mortality on EDP cost - effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields.

     

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