- 學位論文
幽門螺旋桿菌社區篩檢與根除於消化性潰瘍及胃癌防治之成本效益分析
The Cost-effectiveness Analysis of H. pylori Eradication for Preventing Peptic Ulcer and Gastric Cancer: A Community-based Study
摘要
研究背景 消化性潰瘍目前仍然是世界高發病率的疾病之一，會影響病人生活品質且具有高復發率的特性。根除幽門螺旋桿菌已被列為治療消化性潰瘍的方法之一，若能利用初段預防進行除菌治療，進而阻斷病程進展，不僅能提升病患生活品質，亦能節省後續反覆治療的成本花費。彰化縣在2012年開始率先在社區整合式篩檢—萬人健檢及大型預防保健篩檢活動中加入幽門螺旋桿菌糞便抗原檢查篩檢項目，2015年開始，於社區進行大規模的幽門螺旋桿菌篩檢計畫，並連同後續轉介、用藥服務一併納入。至今，所有參加此類活動的50-69歲彰化縣居民均可接受一次免費幽門螺旋桿菌篩檢。 研究目的 (1) 利用彰化縣胃幽門螺旋桿菌社區篩檢計畫評估胃幽門螺旋桿菌感染的危險因子； (2) 進行胃幽門螺旋桿菌糞便抗原檢查結合除菌治療的成本效益分析。 研究方法 本研究針對彰化縣50-69歲民眾於社區整合式篩檢—萬人健檢場次及大型預防保健篩檢活動者進行糞便抗原檢測，針對陽性者施予投藥治療，並以問卷進行個人胃部相關疾病史、用藥史及菸檳酒等生活型態資料收集，以羅吉斯迴歸分析，了解不同病史及生活型態之於幽門桿菌感染及胃部潰瘍疾病間的差異。同時利用文獻回顧得到的消化性潰瘍及幽門桿菌之疾病進展與檢測敏度度等參數，加上彰化地區的實地收案取得幽門桿菌篩檢、用藥史家族史、除菌藥物的成本等相關參數，輔以消化性潰瘍治療健保成本資料，利用馬可夫決策模型進行成本效益分析。 結果 本研究共收錄31,497名個案，胃幽門螺旋桿菌糞便檢查陽性率為38.55%，經轉介總計6,067人接受胃鏡檢查，其中胃部潰瘍比例高達30.5%，十二指腸部位潰瘍亦達20%。 胃幽門螺旋桿菌陽性率女性較男性風險高5% (95%信賴區間：1-1.1 )，陽性率亦隨著年齡增加而增加，相較於50-54歲個案，55-59歲者的干擾因子調整勝算比(aOR)為1.32 (95%信賴區間：1.24-1.4)、60-64歲增加至1.40 (95%信賴區間：1.32-1.50)、65-69歲則為1.42 (95%信賴區間：1.32-1.53)。菸酒檳習慣與胃幽門螺旋桿菌陽性未達。 在幽門螺旋桿菌陽性且轉介進行胃鏡檢查的個案中，女性個案消化系潰瘍的盛行率較男性高 (aOR=1.40, 95%信賴區間：1.25-1.57)，具消化性潰瘍家族史相較於無家族病史者有較高罹患消化系潰瘍風險(aOR=1.22 (95%信賴區間：0.98-1.53)。 利用馬可夫決策模型分析幽門桿菌篩檢及除菌治療介入及不進行介入兩種策略，結果發現進行介入除菌策略花費較少的成本且可獲得較多生命年數，在增量成果效果比方面，介入組之增量成本為-1.76美元，增量效益為0.796人年，遞增成本效果比值(incremental cost-effectiveness ratio,ICER)為-0.497，表示成本少且效益高。 討論 本研究利用社區主動篩檢提供臺灣地區本土幽門螺旋桿菌陽性實證結果，在彰化縣50-69歲民眾陽性率約為四成，陽性個案轉介後的胃部潰瘍盛行率達三成。利用本土實證參數所建構的決策模型推論除菌介入策略除了可獲得較高的健康生命年外，尚可節省成本，屬優勢策略。
並列摘要
Background Peptic ulcer is one of the most morbid diseases in the world. It affects the quality of life of affected patients with a high recurrence rate. H. pylori treatment has been recommended as one of the options for the prevention of peptic ulcer. In Changhua county, the screen of H. pylori has been integrated into the Changhua community-based integrated screening (CHCIS) program since 2012. An extended program of H. pylori screening program together with referral and a following treatment regime has been launched since 2015. All Changhua residents aged 50-69 who join the health check-up or CHCIS can receive a one-shot free H. pylori test until now. Aims The aims of this thesis are (1) to investigate the risk factors associated with H. pylori infection and with the prevalence of gastric ulcer in Changhua County, and (2) to conduct a cost-effectiveness of H. pylori treatment after H. pylori stool antigen testing compared with no intervention. Methods This study targeted at residents aged 50-69 who joined the CHCIS program or other community-based preventive screening activities for stool antigen testing in Changhua. Those tested positive were referral for endoscope and provided with medication for H. pylori. Data on life style, personal medical history such as gastric disease and medication were collect with structured questionnaire. We used logistic regression to investigated factors associated with H. pylori infection and with peptic ulcer. A Markov decision tree model was constructed for the cost-effectiveness analysis for H. pylori eradication for preventing peptic ulcer and gastric cancer. Results A total of 31,497 cases participated in this study. The positive rate of H. pylori infection was 38.55%. Among them, 6,067 cases were referred for endoscopy. The results show that the proportion of gastric ulcer was 30.5%, and the duodenal ulcers was 20%. The positive rate of gastric H.pylori in women was higher than men by 5% (aOR=1.05, 95% CI: 1-1.1). The positive rate increased with age. Compared with those aged 50-54, the adjusted odds ratios (aOR) were 1.32 (95% CI: 1.24-1.4), 1.40 (95% CI: 1.32-1.50), and 1.42 (95% CI: 1.32-1.53) for subjects aged 55-59, 60-64, and 65-69, respectively. The habit of smoking, alcohol drinking, and betel quid chewing were not statistically significantly associated with H. pylori. Among subjects with positive H. Pylori antigen test referring for endoscopy, the prevalence of peptic ulcer in women was higher than in men (aOR=1.40, 95% CI: 1.25-1.570). The prevalence of peptic ulcer in subjects with family history of peptic ulcer was higher than those without family history (aOR=1.22 (95% CI: 0.98-1.53). The cost-effectiveness analysis shows that an intervention strategy of H. Pylori cost less with life years gained. The incremental cost of the intervention group was -1.76 USD, the incremental effectiveness was 0.796 person-years, yielding an estimated ICER of -0.497,It’s means spend less cost to obtain higher benefits. Conclusion This study provides empirical results of H. pylori infection of 40% and the prevalence of peptic ulcer of 30% among those H. pylori infected based on a community-based screening program for residents aged 50-69 in Changhua, Taiwan. The cost-effectiveness analysis shows that a community-based screening for H. pylori following by the treatment regime was a dominate strategy compared with no intervention.