通过检测肝静脉压力阶差能够识别有静脉曲张出血病史的患者进行药物预防的效果。但是，目前尚无研究分析利用常规检测肝静脉压力阶差指导二级预防的费效比。
美国阿拉巴马大学伯明翰分校的M. R. Arguedas博士及其同事利用专门的软件（DATA 3.5，美国麻省Williamstown公司）建立Markov模型。三种不监测血液动力学的二级预防措施包括：仅应用β阻滞剂、联合应用β阻滞剂与单硝酸异山梨酯、仅进行内镜下曲张静脉结扎。另四种二级预防措施在联合应用β阻滞剂/单硝酸异山梨酯或单独应用β阻滞剂时，通过检测一或两次肝静脉压力阶差识别血液动力学无应答者，并进行内镜下曲张静脉结扎。计算每种预防措施在3年内的总预期费用、静脉曲张出血情况和总死亡率。
结果显示，两种最有效的措施为单纯联合治疗、联合治疗时检测两次肝静脉压力阶差。与单纯联合治疗相比，后者增加的成本效益比为136,700美元/延长生存年。随时间范围的扩大或曲张静脉再出血率的增加，这一比例有所改善。
Arguedas博士等指出，在利用血液动力学监测指导静脉曲张再出血的二级预防时，其费效比高度依赖于肝静脉压力阶差检测的费用、预期寿命和再出血率。
Aliment Pharmacol Ther. 2004 Mar;19(5):571-81.
Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding.
Raines DL, Dupont AW, Arguedas MR.
Department of Medicine Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA.
BACKGROUND: : Measurement of the hepatic venous pressure gradient may identify a sub-optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined. METHODS: : A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta-blockers alone, beta-blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta-blockers plus isosorbide mononitrate or beta-blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non-responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years. RESULTS: : The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost-effectiveness ratio of the latter strategy was $136 700 per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re-bleeding were increased. CONCLUSIONS: : The cost-effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re-bleeding rates.
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自动采集 2005-2-23