华东地区颅脑创伤患者行去骨瓣减压术的成本效用分析

Cost-effectiveness of decompressive craniectomy for patients with traumatic brain injury in eastern China

目的研究华东地区颅脑创伤患者行去骨瓣减压术的成本效用。方法抽取《2004年华东六省一市颅脑创伤数据库》中行去骨瓣减压术的患者1 355例。根据患者的住院费用及术后1年的格拉斯哥预后评分(glasgow outcome scale,GOS),计算出患者的寿命年费用和质量调整寿命年费用,再根据国际标准的CRASH预后预示模型计算出患者的不良预后风险作为衡量损伤严重度的指标,根据严重度分层评价其成本效用。结果 1 355例行去骨瓣减压术的颅脑创伤患者随访一年后有37.20%患者预后良好,14.98%的患者存在中度残疾,11.29%的患者存在重度残疾,7.08%的患者仍处于植物状态,29.45%的患者死亡。1355例患者每增加1年寿命所需的费用平均9 992元,而每增加一个质量调整寿命年(QALY)所需的费用平均为14 762元。患者的年寿命住院费用和QALY住院费用随预后不良风险的增高而逐渐增加,当风险≥80%时增加最为明显。当预后不良风险≥80%时的寿命年住院费用及QALY住院费用均显著高于风险<80%时(P<0.001)。结论不良预后风险是去骨瓣减压术是否经济有效的一项重要影响因素。对不良预后风险高的患者行去骨瓣减压术其成本效用低。

Objective Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after traumatic brain injury （TBI）, but its cost- effectiveness remains uncertain. The purpose of the study is to analyze the cost-effectiveness of decompressive craniectomy in eastern China. Methods Using data on length of stay in hospital, costs, and Glasgow Outcome Scale （GOS） up to 12 months after surgery, the average total hospital costs per life year and quality adjusted life-year （QALY） were calculated for patients who had decompressive craniectomy for TBI in 2004 in eastern China. The Corticosteroid Randomization After Significant Head Injury prediction model was used to quantify the severity of TBI. Results Of the 1355 patients with 12-month follow-up data available after the procedure, 504： （37.20%） achieved better outcomes （GOS-5）, 203 （14.98%） were moderately disabled （GOS-4） and 153 （11. 29%） severely disabled （GOS 3）, while 96 （7.08%） were in vegetative state （GOS-2）, and 399 （29.45%） died （GOS-1）. The average costs of per life-year and QALY increased dramatically when the predicted risk of an unfavorable outcome was 80% and over, which were much higher compared to that of less than 80%. Conclusions Risk of unfavorable outcome （Severity of TBI） is the critical influencing factor on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy isnot cost-effective for patients with extremely severe TBI.