- 學位論文
氫離子幫浦阻斷注射劑用於治療非惡性腫瘤上消化道出血病人 之成本效益分析
Cost-effectiveness of the iv proton pump inhibitors in the treatment of non-variceal upper gastrointestinal bleeding
摘要
研究背景：非惡性腫瘤造成的上消化道出血是一種復發性疾病，也是全世界包括台灣地區常見急診住院的原因，住院中的病人也經常發生，出血的病人很容易發生再次出血的情形，而造成龐大的醫療支出，如何有效避免再出血的發生，成為治療的首要目標。目前藥物治療方面的研究指出，出血病人接受質子幫浦阻斷注射劑（PPI）的注射，將有助於減少再出血的可能，然而美國FDA至今仍未核准IV PPI用於此適應症，台灣方面也缺乏此藥物治療相關的成本效益分析。 研究目的：藉由健保資料分析，比較IV PPI 和IV Histamin2- receptor antagonist（H2RA）用於內視鏡止血治療前後，非惡性腫瘤之上消化道出血病人，其成本效益分析。 研究方法：本研究為一項從2002年1月至2004年1月為止，為期共兩年的回顧性世代分析，資料分析來源取自於健保資料庫，採用決策模型分析方式及健康保險機構立場，比較內視鏡止血前後以IV PPI和IV H2-RA治療上消化道出血病人的成本效益分析。病人蒐集須於半年內就醫時不曾被診斷出ICD-9-CM含531、532、533、534，且第一次就診即含有內視鏡止血紀錄之上消化道出血病患，排除所有惡性腫瘤患者，並連續追蹤這些病人達60天，以健保給付價格資料庫來計算實際付出金額，所有的花費計算，以2004年的金額表示，變數的預估經由敏感度分析，治療失敗的指標為再出血的發生，比較所有符合分析條件的兩組，其所有就醫記錄，進行藥物使用、檢查診斷、內視鏡止血、再出血、及耗用金額等比較分析。 研究結果：上消化道出血病人在內視鏡止血治療之後，還是高達7%左右的病人，會再度出現嚴重的出血現象，再出血發生機率會隨著病患年齡、合併症、及藥物使用而增加，在藥物使用方面，NSAID和上消化道出血具高度相關性，而再出血病患治療費用遠大於未再出血的費用。 結論：我們的研究顯示，對於高再出血風險的上消化道出血病患，內視鏡止血治療合併H2RA注射，具有較好的成本效益。
並列摘要
Background: Non-variceal upper gastrointestinal bleeding (UGIB) is a common cause of hospitalization all over the world including in Taiwan. Recent data indicate that IV proton pump inhibitors (PPIs) have the potential to treat UGIB. Despite clinical evidence in favour of IV PPIs, FDA has not yet been proved PPIs in this indication. Data on the cost-effectiveness of this approach in Taiwan is still lacking. Objectives: The objective is to compare the cost- effectiveness of IV PPIs and Histamin2-recptor antagonist（H2-RA）in the treatment of UGIB. We assessed the effect of initial medication choice (ie, PPIs, H2-RA, or others) following endoscopic haemostasis on cost using healthcare claims data in Taiwan . Methods: This study was a 2-year, retrospective longitudinal analysis of data from the healthcare claims in southern Taiwan, with about 3 million members, between January 1, 2002, and January 31, 2004. On the basis of International Classification of Disease, Ninth Revision, Clinical modification (ICD-9-CM), we constructed a decision tree model comparing three main strategies: IV PPIs started、IV H2-RA started and others started in non-variceal UGIB patients following endoscopic therapy. The decision analysis used base case estimates of the most likely clinical scenarios and then used sensitivity analysis to evaluate the strategies. Outcome measure was the 60-day rebleeding rate. Failure is rebleed within 60 days. Effectiveness was reported as the percentage of patients in whom rebleeding was prevented. The model evaluated the rebleeding to initial therapy and the rebleeding prevented by competing different strategies. Results：After endoscopic therapy, rebleeding rate is still high in Taiwan. Rebleeding appears to correlate with clinical characteristics of the patients: it increase with age, comorbidity, and drugs used. Among drugs, NSAIDS are associated with higher risk of UGIB. Conclusion: The analysis demonstrates that the use of IV H2-RA in conjunction with endoscopy haemostasis was both superior effectiveness and lower cost based on the probability determination used in the sensitivity analysis.