椎间盘突出手术的经济效益

一篇新研究显示，相较于非手术治疗，标准开放式椎间盘切除手术可适度节省成本；9月1日的Spine期刊中，研究者发现手术的经济价值有可观的变化，根据使用的术式而有不同费用，但是依旧相对有利。
　　
　　主要研究者、Dartmouth医学院的Anna Tosteson医师写道，我们使用有关资源利用、工作损失、健康相关生活品质等资料来估计每一校正生活品质-年的花费；本研究是SPORT(Spine Patient Outcomes Research Trial)试验的一部份。
　　
　　他们指出，虽然手术花费一般比非手术治疗多，但是手术治疗后两年的健康结果比较好。
　　
　　研究者估计，手术相较于非手术治疗的每一校正生活品质-年的花费范围，从美金34,355到69,403元不等，依每一术式的花费而异。
　　
　　美国神经外科学会主席James Bean医师向Medscape Neurology & Neurosurgery表示，我对此发现并不感到惊讶；手术一开始的确比较贵，但是对于那些一开始较差的检测，也会有重要的改善利益。
　　
　　Bean医师表示，因为手术花费大约是其他治疗方法的两倍，医师往往会考虑保守的方法。
　　
　　【建议保守的方法】
　　Bean医师表示，决定手术之前略做等待是聪明且适当的；如果病患可以在四至六周之内改善，就是最佳选择；但是如果未能如此，且病患持续有疼痛和无法工作等等，那就值得考虑较昂贵的选项，如手术。
　　
　　研究者研究美国13家脊椎诊所的病患，这些病患有持续的背痛和脚痛，确认诊断为椎间盘突出。
　　
　　总共有775名病患接受标准的开放式椎间盘切除手术，416人以非手术方式治疗；研究者使用经认证的仪器(EQ-5D)，且评估资源利用和间接花费。
　　
　　Tosteson医师等人发现，两年时的每一校正生活品质-年之平均差异为0.21，手术较佳(95% CI, 0.16 – 0.25)。
　　手术之每一校正生活品质-年之平均花费

花费	一般族群，美金 (95% CI)	Medicare 健保族群，美金(95% CI)
总数	69,403 (49,523 – 94,999)	34,355 (20,419 – 52,512)
直接医疗	72,181 (56,473 – 92,394)	37,285 (28,364 – 48,993)
间接医疗与生产力	77,300 (60,009 – 99,544)	42,111 (30,976 – 56,284)

　　研究者指出，我们经济评估的强处在于我们可以在分析中考量工作相关生产力的花费，为了从社会观了解手术治疗的经济效益，将这些花费纳入很重要。
　　
　　不过，当我们追踪自我报告的脊椎相关问题导致的工作天数损失时，我们发现有更微妙的生产力损失(例如因为疼痛导致工作效率降低)并未被测量。
　　
　　研究者也指出一些研究限制，包括它是观察式研究设计；他们指出，我们依赖病患自我报告的资源利用和生产力损失来估计花费总数。
　　
　　研究者也指出，因为观察世代和随机世代有高度的交叉，他们提出使用纵向模式评估所治疗病患的花费和结果的综合分析方法。
　　
　　他们指出，虽然这包含了复杂的统计模式，但这个方法的好处之一是，我们使用多数椎间盘突出病患的经验，他们的整体特征在这两世代中并无明显差异。
　　
　　研究者结论表示，我们的综合分析认为，相较于其他一般健康照护介入方式，以手术治疗椎间盘突出代表有合理经济效益的介入方式。
　　
　　研究者宣称没有相关资金上的往来。

 

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