椎間盤突出手術的經濟效益


  September 15, 2008 — 一篇新研究顯示,相較於非手術治療,標準開放式椎間盤切除手術可適度節省成本;9月1日的Spine期刊中,研究者發現手術的經濟價值有可觀的變化,根據使用的術式而有不同費用,但是依舊相對有利。
  
  主要研究者、Dartmouth醫學院的Anna Tosteson醫師寫道,我們使用有關資源利用、工作損失、健康相關生活品質等資料來估計每一校正生活品質-年的花費;本研究是SPORT(Spine Patient Outcomes Research Trial)試驗的一部份。
  
  他們指出,雖然手術花費一般比非手術治療多,但是手術治療後兩年的健康結果比較好。
  
  研究者估計,手術相較於非手術治療的每一校正生活品質-年的花費範圍,從美金34,355到69,403元不等,依每一術式的花費而異。
  
  美國神經外科學會主席James Bean醫師向Medscape Neurology & Neurosurgery表示,我對此發現並不感到驚訝;手術一開始的確比較貴,但是對於那些一開始較差的檢測,也會有重要的改善利益。
  
  Bean醫師表示,因為手術花費大約是其他治療方法的兩倍,醫師往往會考慮保守的方法。
  
  【建議保守的方法】
  Bean醫師表示,決定手術之前略做等待是聰明且適當的;如果病患可以在四至六週之內改善,就是最佳選擇;但是如果未能如此,且病患持續有疼痛和無法工作等等,那就值得考慮較昂貴的選項,如手術。
  
  研究者研究美國13家脊椎診所的病患,這些病患有持續的背痛和腳痛,確認診斷為椎間盤突出。
  
  總共有775名病患接受標準的開放式椎間盤切除手術,416人以非手術方式治療;研究者使用經認證的儀器(EQ-5D),且評估資源利用和間接花費。
  
  Tosteson醫師等人發現,兩年時的每一校正生活品質-年之平均差異為0.21,手術較佳(95% CI, 0.16 – 0.25)。
  手術之每一校正生活品質-年之平均花費

花費

一般族群,美金 (95% CI)

Medicare 健保族群,美金(95% CI)

總數

69,403 (49,523 – 94,999)

34,355 (20,419 – 52,512)

直接醫療

72,181 (56,473 – 92,394)

37,285 (28,364 – 48,993)

間接醫療與生產力

77,300 (60,009 – 99,544)

42,111 (30,976 – 56,284)


  研究者指出,我們經濟評估的強處在於我們可以在分析中考量工作相關生產力的花費,為了從社會觀瞭解手術治療的經濟效益,將這些花費納入很重要。
  
  不過,當我們追蹤自我報告的脊椎相關問題導致的工作天數損失時,我們發現有更微妙的生產力損失(例如因為疼痛導致工作效率降低)並未被測量。
  
  研究者也指出一些研究限制,包括它是觀察式研究設計;他們指出,我們依賴病患自我報告的資源利用和生產力損失來估計花費總數。
  
  研究者也指出,因為觀察世代和隨機世代有高度的交叉,他們提出使用縱向模式評估所治療病患的花費和結果的綜合分析方法。
  
  他們指出,雖然這包含了複雜的統計模式,但這個方法的好處之一是,我們使用多數椎間盤突出病患的經驗,他們的整體特徵在這兩世代中並無明顯差異。
  
  研究者結論表示,我們的綜合分析認為,相較於其他一般健康照護介入方式,以手術治療椎間盤突出代表有合理經濟效益的介入方式。
  
  研究者宣稱沒有相關資金上的往來。

Surgery for Intervertebral Disk Herniation Cost-Effective

By Allison Gandey
Medscape Medical News

September 15, 2008 — Standard open diskectomy is moderately cost-effective compared with nonsurgical treatment, a new study shows. Reporting in the September 1 issue of Spine, researchers found the economic value of surgery varied considerably, depending on the method used for assigning surgical costs, but remained relatively favorable.

"We used data collected on resource utilization, work loss, and health-related quality of life to estimate cost per quality-adjusted life-year gained," write the researchers, led by Anna Tosteson, ScD, from Dartmouth Medical School, in Hanover, New Hampshire. The study is part of the Spine Patient Outcomes Research Trial (SPORT).

Although surgery was more costly than nonoperative treatment, health outcomes over 2 years were better among those treated surgically.

Although surgery was more costly than nonoperative treatment, health outcomes over 2 years were better among those treated surgically, they note.

The investigators estimate the costs per quality-adjusted life-year gained with surgery compared with nonoperative treatment ranges from $34,355 to $69,403, depending on the cost of surgery.

"I'm not surprised by the findings," James Bean, MD, president of the American Association of Neurological Surgeons, told Medscape Neurology & Neurosurgery. "Surgery tends to be more expensive initially but can have important benefits even for those with worse initial health measures."

Dr. Bean says that because surgery can cost approximately two times as much as other options, physicians should consider a conservative approach.

Conservative Approach Recommended

"It is wise and proper to wait before initiating surgery," Dr. Bean said. "If the patient can improve in 4 to 6 weeks — that is the best option. But if this is not the case, and the patient continues to experience pain and is missing work and so forth, then a higher-cost option such as surgery may be worthwhile."

Investigators studied individuals from 13 spine clinics in the United States. Patients had persistent back and leg pain and a confirmed diagnosis of intervertebral disk herniation.

A total of 775 participants underwent standard open diskectomy, and 416 were treated nonoperatively. Researchers used a validated instrument (the EQ-5D) and evaluated resource utilization and indirect costs.

Dr. Tosteson and her team found the mean difference in quality-adjusted life-year gained over 2 years was 0.21 in favor of surgery (95% CI, 0.16 – 0.25).

Mean Cost per Quality-Adjusted Life-Year Gained for Surgery
Costs General Population, $ (95% CI) Medicare Population, $ (95% CI)
Total 69,403 (49,523 – 94,999) 34,355 (20,419 – 52,512)
Direct medical 72,181 (56,473 – 92,394) 37,285 (28,364 – 48,993)
Direct medical and productivity 77,300 (60,009 – 99,544) 42,111 (30,976 – 56,284)

"A strength of our economic evaluation was our ability to consider work-related productivity costs in the analysis. To understand the cost-effectiveness of surgical treatment from a societal perspective, it is important for such costs to be included," note the researchers.

"However, while we tracked self-reported work days lost because of spine-related problems, we acknowledge that more subtle productivity losses (such as less efficient work due to pain) were not measured."

The investigators also point to a number of limitations to their work, including its observational design. "We relied on patient self-reports of resource use and productivity losses to estimate total costs," they note.

The researchers also point out that due to the high degree of crossover in both the observational and randomized cohorts, they presented a pooled analysis that used longitudinal modeling to evaluate costs and outcomes of participants as they were treated.

"Although this involves complex statistical models," they note, "an advantage of this approach is that we used the experience of a large number of persons with intervertebral disk herniation whose overall characteristics did not differ statistically between cohorts."

The investigators conclude, "Our comprehensive analysis suggests that surgical treatment of herniated disk represents a reasonably cost-effective intervention when compared with other common healthcare interventions."

The researchers have disclosed no relevant financial relationships.

Spine. 2008;33:2108-2115.Abstract

    
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