胃肠肿瘤手术患者丙胺酰-谷氨酰胺强化肠外营养应用及按模型的卫生经济学推测

A short-time economic evaluation of various modalities of glutamine dipeptide-enriched parenteral nutrition support in patients undergoing elective surgery for gastrointestinal tumors using decision-tree model

目的对胃肠肿瘤限期手术患者不同时期应用丙胺酰-谷氨酰胺（Ala-Gln）双肽强化肠外免疫营养支持方案进行短期卫生经济学评价，为临床营养支持决策提供依据。方法本研究为前瞻性队列研究，从费用支付者的角度调查比较术后早期与围手术期应用Ala-Gln双肽免疫肠外营养对患者临床结局和短期生命质量的影响；构建决策树模型，比较两种方案的成本/效果和成本/效用，并进行敏感度分析。结果107例患者纳入分析，围手术期应用组（A组）与术后早期应用组（B组）比较，术后第8天患者体质量减少≥5%和术后并发症发生率两组差异无统计学意义（72.1%比78.1%，χ2＝0.509，P＝0.498；2.32%比4.69%，χ2＝0.060，P＝0.806）；淋巴细胞计数（TLC）、血清前白蛋白（PA）、血清白蛋白（Alb）、术后胃肠功能恢复时间、营养相关住院时间（LOSNDI）和平均直接医疗成本两组比较差异有统计学意义[PA：（208.19±56.92）mg/L比（187.97±62.05）mg/L，t＝2.283，P＝0.039；Alb：（33.82±3.91）×109比（31.96±4.57）×109，t＝2.184, P＝0.036；TLC：（1.19±0.55）×109比（0.89±0.66）×109，t＝2.461, P＝0.015；术后胃肠功能恢复时间：（3.06±0.28）d比（3.39 ± 0.34）d，t＝－3.675, P＝0.000；LOSNDI：（16.84±2.92）d比（18.52±3.47）d，t＝－2.613, P＝0.011；平均直接医疗成本：（17 029.05±317.28）元比（15 610.64±292.56）元，t＝23.764, P＝0.000]；以LOSNDI作为效果测量指标，A组的增益成本效果为844.3元；以质量调整生命年（QALYs）作为效用测量指标，A组的增益成本效用为70 920.5元，净货币效益B组高于A组；在敏感度分析范围内，成本效用分析结果并未受到参数不确定性的影响。结论以当地人均国内生产总值作为支持意愿评判界值时，术后早期应用Ala-Gln双肽免疫肠外营养是兼顾临床效果和成本费用的相对优选方案。

ObjectiveTo assess the short-time economics of various glutamine dipeptide-enriched parenteral nutrition （PN） for patients undergoing elective surgery for gastrointestinal tumors, with an attempt to provide evidence for decision makers on clinical nutrition support.MethodsA prospective cohort study was designed. From payer/disburser＇s perspective, a cost-effectiveness decision-tree model was developed to assess the clinical outcomes and short-time economic effects of glutamine dipeptide-enriched PN that used in different time points （early postoperative or perioperative）. Cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness analysis were adopted in the decision-tree model. One-way sensitivity analysis was performed to determine the robustness of the results.ResultsTotally 107 patients were included. There was no significant difference between the perioperative alanine（Ala） glutamine（Gln） nutrition support （group A） and early postoperative Ala-Gln nutrition support （group B） in the ratio of 5% weight declines on the 8th day after surgery and infection-related postoperative complications （72.1% vs. 78.1%, χ2=0.509, P=0.498 and 2.32% vs. 4.69%, χ2=0.060, P=0.806）. The levels of prealbumin （PA） and albumin（Alb） and the level of total lymphocyte count（TLC） also the time of recovering gastrointestinal function, length of stay nutritional discharge index（LOSNDI）, and direct costs were significantly different [PA： （208.19±56.92）mg/L vs. （187.97±62.05）mg/L, t=2.283, P=0.039; Alb： （33.82±3.91）×109vs. （31.96±4.57）×109,t=2.184, P=0.036; TLC： （1.19±0.55）×109vs. （0.89±0.66）×109,t=2.461, P=0.015; the time of recovering gastrointestinal function（3.06±0.28）d vs. （3.39 ± 0.34）d, t=-3.675, P=0.000; LOSNDI： （16.84±2.92）d vs. （18.52 ±3.47）d, t=-2.613, P=0.011; direct costs： ￥（17 029.05±317.28） vs. ￥（15 610.64±292.56）, t=23.764, P=0.000]. When LOSNDI and quality-adjusted life years （QALYs） were estimated as indicators of effectiveness, the incremental cost-effectiveness ratios and incremental cost-utility ratios of group A were ￥844.3 and ￥70 920.5, respectively. Net monetary benefit of group B was more than that of group A. One-way sensitivity analysis showed that parameters had no significant effect on the model.ConclusionWhen using local per capita gross domestic product as threshold, early postoperative Ala-Gln PN was more economical than perioperative Ala-Gln PN strategy evaluation.