抗菌药物卫生经济学评价及外部性分析的系统评价

The economic evaluation of antibacterial drugs and externalities from antibacterial drug uses:a systematic review

目的对抗菌药物外部性的卫生经济学评价进行系统评价。方法计算机检索PubMed、EMbase、The Cochrane Library、CNKI、WanFang Data和VIP数据库,搜集抗菌药物外部性的药物卫生经济学评价,检索时限均为建库至2020年12月31日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,进行描述性分析。结果共纳入14个研究。其中13个研究考虑了抗菌药物耐药的负外部性对于成本和/或效果的影响;1个研究分析了抗菌药物在感染防控方面的正外部性;没有研究同时分析了正、负外部性。分析负外部性的方法包括:仅计算了抗菌药物单次处方或单位剂量耐药成本,和通过建立决策树模型,模拟病原菌耐药导致治疗失败后,增加的后续治疗的成本和效果;分析正外部性的方法为基于人群建立动力学模型,计算因抗菌药物治疗控制了疾病传播,从而带来的健康收益和节约的治疗成本。结论抗菌药物的药物经济学评价应同时纳入抗菌药物的正、负外部性,考虑外部性对于成本和效果的影响。未来的研究应从更广阔的视角出发,通过建立传染病动力学模型,计算外部性的相关成本和效果。另外,在研究期限较长时,可尝试使用伤残调整寿命年替代质量调整寿命年,以获得更准确的健康效用值,并对成本、效果进行贴现处理。

Objective To systematically review the health economic evaluation studies in which externalities of antibacterial drug uses were identified.Methods PubMed,EMbase,The Cochrane Library,CNKI,WanFang Data and VIP databases were electronically searched to collect health economic evaluation studies in which externalities of antibacterial drug uses were identified from inception to December 31 st,2020.Two reviewers independently screened literature,extracted data and assessed the risk of bias of included studies.Descriptive analysis was then performed.Results A total of 14 studies were included.Negative externalities and their impacts on costs and/or effectiveness were examined in 13 literature,and positive externalities in terms of an improvement in disease control were included in only one study.No study was found in which both negative and positive externalities were included.The methods used to quantify negative externalities included:only costs associated with drug resistance per prescription or per unit were calculated;both costs and health impacts associated with the second/third line treatments followed a treatment failure(due to drug resistance)were calculated using a decision tree.In one study in which positive externalities were measured,both health gain and cost reduction from an improvement in disease control(as a benefit of antibacterial drug uses)were calculated by constructing a dynamic model at the population level.Conclusions We propose that both the positive and negative externalities should be included in health economic evaluation.This can be achieved by measuring the relevant costs and health impacts in a broader perspective,using a disease-transmission dynamic model.In addition,to achieve an improved health utility measurement,disability-adjusted-life years rather than quality-adjusted-life years should be encouraged for use.Finally,both costs and effectiveness should be discounted.