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  • 學位論文

亞太平洋結直腸篩檢評分系統(APCS score)的效益及成本效用分析

Effectiveness and Cost-utility analysis of Asia-Pacific Colorectal Screening (APCS) Score

指導教授 : 高浩雲
共同指導教授 : 邱亨嘉(Herng-Chia Chiu)

摘要


研究背景與目的 糞便潛血檢查於國內用於大腸癌篩檢已行之有年且有所成效,而其他國家使用各種不同的篩檢策略也都有其應用的環境和條件。近年由於篩檢風險評分的系統(如亞太平洋結直腸篩檢分數,APCS Score)有較新的進展,讓我們在執行大腸鏡或其他篩檢前就可以先區分出高風險族群。故本研究希望能夠探討在使用亞太平洋結直腸篩檢分數做接受大腸鏡檢查前風險區分的效力及分組後的成本效益差異。 研究方法 本研究採回溯性研究設計,利用某醫學中心2016年一月至2019年十二月接受健康檢查及糞便篩檢者的病歷資料進行分析,並將受檢者依照亞太平洋結直腸篩檢分數分組(如≧4分的高風險組及<4分的中低風險組)並計算其非高風險腺瘤及高風險腫瘤的偵測率等,而後利用文獻數據及衛服部公告之收費標準推估不同風險分組大腸鏡檢查的成本效益。統計方法採用SPSS 22.0統計軟體及TreeAge Pro決策分析軟體進行評估。另外,亦嘗試利用推論性統計結果去比較糞便篩檢和APCS Score對於風險區分的效力差異。 研究結果 經由APCS Score分組後,切割分數以上的組別的病灶偵測率確實顯著高於未滿分數的組別(以4分作切割點為例:任何病灶:68.84% vs. 49.55%、非高風險腺瘤:31.16% vs. 16.86%、高風險腫瘤:8.89% vs. 3.28%,p值皆<0.001),且在支付意願閾值為新台幣20,000元的情況下,用3分作為切割點比起4分來的更具成本效益(ICER:新台幣-9,764.3元/降低1%結直腸癌發生率)。另外,APCS Score用3分作為切割點與糞便篩檢能偵測出出高風險腫瘤的能力相似,但是否值得取代糞便篩檢或是與糞便篩檢合併使用使否具成本效益,則需後續研究探討。  結論 針對一般考慮作檢查的民眾(不論是否符合國健署糞便篩檢條件)和希望替無症狀患者安排檢查的醫療提供者而言,APCS Score 3分以上接受檢查,比較具成本效益;如公司團體要安排員工/成員健檢,亦可考慮用同樣策略,但若把總花費作為最大考量的話,4分作切割點,則檢查出一個高風險腫瘤的花費較低。對於政策制定者來說,可考慮用APCS score(3分作為切割點)取代糞便篩檢或是與之配合使用

並列摘要


Background & Objective: In last decade, our government had some progress in promoting fecal immunochemical test (FIT) as the screening test for colorectal cancer. Other countries have their own effective strategy responding to their condition also. Due to development of simple clinical scoring system (e.g. Asia-Pacific Colorectal screening score, APCS score) in recent years, we could recognize high risk population before definite examination for colon cancer screening. Thus, our aim in this study is to re-examine the effectiveness and cost-effectiveness of risk-sorting strategy (APCS score) for colonoscopy. Methods: We analyze the medical records retrospectively of subjects who received health checkup and FIT in a medical center located in south Taiwan from Jan. 2016 to Dec. 2019. Subjects were divided into groups by the APCS scoring system (e.g. score ≧4 as high risk and <4 as low-to-intermediate risk) and we calculated detection rates for non-advanced adenoma detection rate and advanced neoplasm in each group respectively. We use data in literatures and announced prices of colonoscopy and related treatment by our national health insurance administration and analysis the cost-effectiveness by using statistical software such as SPSS 20.0 and TreeAge Pro. Besides, we also try to compare the effectiveness between FIT and APCS score by the result of inferential statistics. Outcome: The detection rates of all kinds of lesions were significantly higher in the group above the cut-off point than those below the point (e.g. Use score 4 as cut-off point: any polyps or tumor: 68.84% vs. 49.55%; non-advanced adenoma:31.16% vs. 16.86%, advanced neoplasm: 8.89% vs. 3.28%, all p-values < 0.001) and under the level of 20,000 NTD as the threshold of willingness to pay(WTP), sorting individuals with score 3 has more cost-effectiveness than score 4 (ICER: -9,764.3 NTD/ 1% reduction of colorectal cancer incidence.) Besides, the ability to detect advanced neoplasia of both sorting strategies (APCS score with cut-off point at score 3 and FIT) are similar but need further research to determine if it’s worth to substitute FIT by APCS score or if it’s cost-effective to combine two strategies. Conclusion: For individual who is considering the colon examination (no matter meets current criteria for FIT or not) or medical supplier who wants to arrange examination for their asymptomatic patient, there’ll be more cost-effective to receive colonoscopy if one’s APCS score is 3 or above. For administrator who wants to arrange health checkup for their employees/members could take the same strategy, however, if total cost of examination is the most important consideration, use score 4 as cut-off point might have lowest cost to find an advanced neoplasia. For policy makers, sorting risk groups before colonoscopy with APCS score (use score 3 as cut-off point) instead of current FIT or combined use of both strategies could be considered.

參考文獻


英文文獻
Aronsson, M., Carlsson, P., Levin, L. A., Hager, J., & Hultcrantz, R. (2017). Cost-effectiveness of high-sensitivity faecal immunochemical test and colonoscopy screening for colorectal cancer. Br J Surg, 104(8), 1078-1086. doi:10.1002/bjs.10536
Chiu, H. M., Ching, J. Y., Wu, K. C., Rerknimitr, R., Li, J., Wu, D. C., . . . Asia-Pacific Working Group on Colorectal, C. (2016). A Risk-Scoring System Combined With a Fecal Immunochemical Test Is Effective in Screening High-Risk Subjects for Early Colonoscopy to Detect Advanced Colorectal Neoplasms. Gastroenterology, 150(3), 617-625 e613. doi:10.1053/j.gastro.2015.11.042
Cross, A. J., Robbins, E. C., Pack, K., Stenson, I., Kirby, P. L., Patel, B., . . . Wooldrage, K. (2020). Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study. Gut. doi:10.1136/gutjnl-2019-320036
De Palma, F. D. E., D'Argenio, V., Pol, J., Kroemer, G., Maiuri, M. C., & Salvatore, F. (2019). The Molecular Hallmarks of the Serrated Pathway in Colorectal Cancer. Cancers (Basel), 11(7). doi:10.3390/cancers11071017

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