下肢动脉定期全程修复防治糖尿病合并下肢动脉硬化闭塞症的成本效用预测分析

辛文琳; 孙晓伟; 虞泽星; 李丽; 范恩芳; 朱晓霞; 刘春峰; 倪春明; 汤敬东

doi:10.16766/j.cnki.issn.1674-4152.002899

下肢动脉定期全程修复防治糖尿病合并下肢动脉硬化闭塞症的成本效用预测分析

doi: 10.16766/j.cnki.issn.1674-4152.002899

1.
上海市浦东医院全科医学科，上海 200120
2.
上海市浦东新区祝桥街道社区卫生服务中心，上海 201323
3.
上海市浦东新区花木街道社区卫生服务中心，上海 201204
4.
上海市浦东新区北蔡街道社区卫生服务中心，上海 201204
5.
上海市浦东新区泥城街道社区卫生服务中心，上海 201306
6.
上海市浦东新区书院街道社区卫生服务中心，上海 201304
7.
上海市浦东新区万祥街道社区卫生服务中心，上海 201313
8.
上海市浦东新区芦潮港街道社区卫生服务中心，上海 201309
9.
上海市浦东医院血管外科

基金项目:

上海市卫生健康委员会科研项目 202150004

详细信息

通讯作者:
汤敬东，E-mail：drtangjingdong@126.com

中图分类号: R587.1R543.6
计量
- 文章访问数: 192
- HTML全文浏览量: 60
- PDF下载量: 7
- 被引次数: 0
出版历程
- 收稿日期: 2022-03-23
- 网络出版日期: 2023-04-19

Predictive analysis of cost utility of lower extremity artery repair in prevention of diabetes and lower extremity arteriosclerosis obliterans

1.
Department of General Medicine, Shanghai Pudong Hospital, Shanghai 200120, China

摘要

摘要: 目的分析下肢动脉定期全程修复防治糖尿病合并下肢动脉硬化闭塞症(ASO)的成本效用，论证下肢动脉全程修复治疗方案在社区糖尿病患者管理中的应用价值。方法于2020年12月—2021年2月通过文献研究和上海市浦东医院血管外科专家咨询，进行糖尿病合并下肢动脉病变的状态分类、转移概率、成本、质量调整生命年等相关数据采集，建立糖尿病合并ASO马尔科夫模型，生成常规治疗和下肢动脉定期全程修复治疗下的队列数据，并结合治疗成本、质量调整生命年产出进行成本效用比较。结果模拟样本为1 000例，常规治疗下，有18.5%(185例)的患者会在末期发生溃疡，截肢率为50.3%(503例)，死亡率为36.7%(367例)；下肢动脉定期全程修复治疗下，末期溃疡发生率在10%以下，截肢率为1.0%~4.9%，死亡率为0.7%~3.3%。定期进行下肢动脉全程修复治疗时，每位糖尿病患者在20年间的平均治疗成本比常规治疗高出397 476.8~706 237.5元，增量成本效用比为129 087.4~213 034.5元/质量调整生命年。结论下肢动脉定期全程修复的增量成本效用比的最低值低于1倍的上海市2019年人均国内生产总值，最高值低于3倍的上海市2019年人均国内生产总值，值得纳入上海市糖尿病合并下肢动脉硬化闭塞症患者糖尿病足防治先进适宜技术范围。
- 下肢动脉硬化闭塞症 /
- 糖尿病 /
- 全程修复治疗 /
- 马尔科夫模型 /
- 成本 /
- 效用
Abstract: Objective To analyse the cost-effectiveness of regular full-course repair of lower extremity arteries in the prevention and treatment of diabetes complicated with lower extremity arteriosclerosis obliterans (ASO), to demonstrate the application value of the full-course repair of lower extremity arteries in the management of diabetes patients in the community. Methods Literature research and consultation with Shanghai Pudong Hospital ' s vascular surgery experts were conducted from December 2020 to February 2021. Status classification, transition probability, cost, quality-adjusted life year and other related data of diabetes complicated with lower extremity arterial disease were collected to establish diabetes combined with the Markov model of lower extremity ASO, generate cohort data under conventional treatment and regular full-course repair of lower extremity arteries and compare the cost-effectiveness of treatment costs and quality-adjusted life-year output. Results The simulated sample was 1 000 cases under conventional treatment, and 18.5% (185 cases) of patients developed ulcers in the terminal stage, with an amputation rate of 50.3% (503 cases) and a mortality rate of 36.7% (367 cases). Under regular full-course repair of lower limb arteries, the rate of terminal ulcers was less than 10%, the rate of amputation was 1.0%-4.9% and the mortality rate was between 0.7%-3.3%. When the lower extremity arterial repair treatment was performed regularly, the average treatment cost of each diabetic patient in 20 years was 397 476.8-706 237.5 yuan higher than that of conventional treatment, and the incremental cost-utility ratio was 129 087.4-213 034.5 yuan/quality-adjusted life year. Conclusion The lowest value of the incremental cost-utility ratio of regular full-course repair of lower extremity arteries is less than the GDP per capita of Shanghai in 2019, and the highest value is less than three times the GDP per capita of Shanghai in 2019, which is worthy of being included in the advanced and appropriate technology for prevention and treatment of diabetes foot in diabetes patients with lower limb ASO in Shanghai.
- Arteriosclerosis obliterans /
- Diabetes /
- Full repair treatment /
- Markov model /
- Cost /
- Utility

HTML全文

图 1 马尔科夫模型状态转移图

Figure 1. State transition diagram of Markov model

下载: 全尺寸图片幻灯片

图 2 下肢动脉定期全程修复治疗与常规治疗下的无溃疡人数变化比较

Figure 2. Changes in the number of ulcer-free patients treated with regular whole-course repair of lower extremity arteries compared with conventional treatment

下载: 全尺寸图片幻灯片

图 3 常规治疗方案下糖尿病合并下肢动脉硬化闭塞症20年疾病状态分布预测结果

Figure 3. Predicted results of disease status distribution of diabetes mellitus with lower extremity arteriosclerosis obliterans over 20 years under conventional treatment regimens

下载: 全尺寸图片幻灯片

图 4 定期治疗方法下糖尿病合并下肢动脉硬化闭塞症20年疾病状态分布预测结果

Figure 4. Predicted results of disease status distribution of diabetes mellitus with lower extremity arteriosclerosis obliterans over 20 years under regular treatment methods

下载: 全尺寸图片幻灯片

表 1 糖尿病合并下肢动脉硬化闭塞症各状态间转移概率

Table 1. Transition probabilities between states of diabetes mellitus with lower extremity arteriosclerosis obliterans

状态转移	具体内涵	常规治疗	下肢动脉定期全程修复治疗
无溃疡→新溃疡	无溃疡症状的患者出现溃疡的概率	0.081^[17]	-^a
新溃疡→溃疡未愈	已经出现溃疡的患者溃疡依然未愈合的概率	0.25	0.25
新溃疡→溃疡愈合	已经出现溃疡的患者溃疡愈合的概率	0.75^[15]	0.75^[15]
溃疡未愈→截肢	已经出现溃疡的患者恶化到需要截肢的概率	0.38^[15]	0.38^[15]
溃疡愈合→截肢	溃疡已经愈合的患者仍需要接受截肢手术处理的概率	0.035^[15]	0.035^[15]
溃疡愈合→新溃疡	溃疡已经愈合的患者再次出现溃疡的概率	0.316^[17]	0.316^[17]
截肢→再截肢	截肢后再次截肢的概率	0.125^[17]	0.125^[17]
截肢→死亡	截肢后死亡的概率	0.22^[17]	0.22^[17]
再截肢→死亡	再次截肢后死亡的概率	0.22^[17]	0.22^[17]
注：0.001≤a≤0.005。转移周期为1年。

下载: 导出CSV

表 2 糖尿病足治疗成本

Table 2. Treatment costs of diabetic foot

干预方案	直接治疗成本
糖尿病基础治疗	2015年为900元/月×12个月(800~1 000元/月)^[18]；按2019年贴现为1 094元/月×12个月
溃疡治疗(开放手术治疗)	53 272.89元^a
截肢手术及相关治疗	首次，20 000元^b；二次，50 585元^{[17, 19]}
减容治疗(如准分子激光消蚀术)	40 000元^c
注：^a为2019年上海市各医院血管外科下肢动脉硬化闭塞症开放手术治疗平均费用；^b为上海市2019年血管外科下肢动脉硬化闭塞症收治病例截肢费用；^c为上海市浦东医院准分子激光消蚀术定价。

下载: 导出CSV

参考文献(23)

[1]	郑月宏, 宋希涛. 下肢动脉硬化闭塞症治疗进展与展望[J]. 中华外科杂志, 2021, 59(12): 961-964. doi: 10.3760/cma.j.cn112139-20210923-00453 ZHENG Y H, SONG X T. Progress and prospect of the treatment of lower extremity arteriosclerosis obliterans[J]. Chinese Journal of Surgery, 2021, 59(12): 961-964. doi: 10.3760/cma.j.cn112139-20210923-00453
[2]	中华医学会糖尿病学分会, 中华医学会感染病学分会, 中华医学会组织修复与再生分会. 中国糖尿病足防治指南(2019版)(Ⅱ)[J]. 中华糖尿病杂志, 2019, 11(3): 161-162, 189. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm Chinese Diabetes Soiety, Chinese Society of Infectious Diseases, Chinese Society for Tissue Repair and Regeneration. Chinese guideline on prevention and management of diabetic foot (2019 edition) (Ⅱ)[J]. Chinese Journal of Diabetes Mellitus, 2019, 11(3): 161-162, 189. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm
[3]	黄彩莲, 张淑琴. 糖尿病下肢动脉硬化闭塞症的外科临床疗效及护理研究[J]. 糖尿病新世界, 2019, 22(15): 145-146. https://www.cnki.com.cn/Article/CJFDTOTAL-TNBX201915086.htm HUANG C L, ZHANG S Q. Clinical efficacy and nursing of surgical treatment for diabetic lower extremity arteriosclerosis obliterans[J]. Diabetes New World, 2019, 22(15): 145-146. https://www.cnki.com.cn/Article/CJFDTOTAL-TNBX201915086.htm
[4]	王鸿铭, 于翔. 糖尿病合并下肢动脉硬化闭塞症患者介入治疗的护理干预[J]. 双足与保健, 2019, 28(18): 112-113. https://www.cnki.com.cn/Article/CJFDTOTAL-SZBJ201918061.htm WANG H M, YU X. Nursing intervention of interventional therapy for patients with diabetes mellitus and lower extremity arteriosclerosis obliterans[J]. Biped and Health, 2019, 28(18): 112-113. https://www.cnki.com.cn/Article/CJFDTOTAL-SZBJ201918061.htm
[5]	朱虹, 叶婷婷, 沈飞霞. 从经典病例看糖尿病足分级诊疗的迫切性[J]. 中华糖尿病杂志, 2017, 9(2): 143-144. ZHU H, YE T T, SHEN F X. To explore the urgency of hierarchical diagnosis and treatment of diabetic foot from the classic cases[J]. Chinese Journal Of Diabetes Mellitus, 2017, 9(2): 143-144.
[6]	王甦平, 马佳莉, 朱伟俊, 等. 社区糖尿病患者分级诊疗依从性影响因素分析[J]. 中华全科医学, 2019, 17(7): 1164-1166, 1221. doi: 10.16766/j.cnki.issn.1674-4152.000891 WAGN S P, MA J L, ZHU J W, et al. Analysis of factors influencing community diabetic patients on the compliance of tiered medical services[J]. Chinese Journal of General Practice, 2019, 17(7): 1164-1166, 1221. doi: 10.16766/j.cnki.issn.1674-4152.000891
[7]	张玉彩, 谢春, 香利强, 等. 紧密型医联体模式下全科医学科建设探索[J]. 中华全科医学, 2019, 17(4): 661-665. doi: 10.16766/j.cnki.issn.1674-4152.000761 ZHANG Y C, XIE C, XIANG L Q, et al. Exploration of the construction of general medicine department under the close medical association[J]. Chinese Journal of General Practice, 2019, 17(4): 661-665. doi: 10.16766/j.cnki.issn.1674-4152.000761
[8]	上海市人民政府新闻办公室. 浦东新区开创全科统筹门诊, 为分级诊疗探索全新途[EB/OL]. (2018-05-10)[2022-01-02]. http://www.shio.gov.cn/sh/xwb/n782/n783/u1ai17028.html. Information Office Of Shanghai Municipality. Pudong New Area has created a general practice outpatient clinic, exploring a new way for hierarchical medical system[EB/OL]. (2018-05-10)[2022-01-02]http://www.shio.gov.cn/sh/xwb/n782/n783/u1ai17028.html.
[9]	新民晚报. 上海发布首批30个"创新医疗服务品牌"[EB/OL]. (2018-12-27)[2022-01-02]. https://baijiahao.baidu.com/s?id=1620968071183285091&wfr=spider&for=pc.
[10]	杨敏杰, 周晟, 孟庆刚. 基于马尔可夫链的中医药疗效预测模型构建与探索[J]. 中华中医药学刊, 2018, 36(7): 1594-1597. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYHS201807016.htm YANG M J, ZHOU S, MENG Q G. Construction and exploration of TCM clinical efficacy evaluation based on Markov Model[J]. Chinese Archives of Traditional Chinese Medicine, 2018, 36(7): 1594-1597. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYHS201807016.htm
[11]	VASSILIOU P C G, GEORGIOU A C. Markov and Semi-Markov Chains, processes, systems, and emerging related fields[J]. Mathematics, 2021, 9(19): 2490.
[12]	李琳琳, 李光新, 王宾. 保守与介入治疗Fontaine Ⅱ期下肢动脉硬化闭塞症患者近期和远期疗效对比[J]. 中华普通外科杂志, 2021, 36(12): 931-935. https://www.cnki.com.cn/Article/CJFDTOTAL-WMIA201856069.htm LI L L, LI G X, WANG B. Comparison of short and long term curative effect between conservative and interventional therapy in Fontaine stage Ⅱ patients with lower extremity arteriosclerosis obliterans[J]. Chinese Journal of General Surgery, 2021, 36(12): 931-935. https://www.cnki.com.cn/Article/CJFDTOTAL-WMIA201856069.htm
[13]	黄江涛, 王刚. 早期介入治疗下肢动脉硬化闭塞症的疗效及安全性评价[J]. 基层医学论坛, 2019, 23(32): 4727-4728. https://www.cnki.com.cn/Article/CJFDTOTAL-YXLT201932104.htm HUANG J T, WANG G. To evaluate the efficacy and safety of early interventional therapy for lower extremity arteriosclerosis obliterans[J]. The Medical Forum, 2019, 23(32): 4727-4728. https://www.cnki.com.cn/Article/CJFDTOTAL-YXLT201932104.htm
[14]	谷涌泉, 郭建明. 糖尿病膝下动脉病变腔内治疗的新进展[J]. 中国微创外科杂志, 2017, 17(4): 289-293. https://www.cnki.com.cn/Article/CJFDTOTAL-ZWWK201704001.htm GU Y Q, GUO J M. Noval progress of endovascular treatment of diabetic below knee arteries lesions[J]. Chinese Journal of Minimally Invasive Surgery, 2017, 17(4): 289-293. https://www.cnki.com.cn/Article/CJFDTOTAL-ZWWK201704001.htm
[15]	NEAL R B, EVERARDO F, MICHAEL B, et al. The accuracy and cost-effectiveness of strategies used to identify peripheral artery disease among patients with diabetic foot ulcers[J]. J Vasc Surg, 2016, 64(6): 1682-1690.
[16]	BEAYDET A, CLEGG J, THURESSON P O, et al. Review of utility values for economic modeling in type 2 diabetes[J]. Value Health, 2014, 17(4): 462-470.
[17]	中华医学会糖尿病学分会, 中华医学会感染病学分会, 中华医学会组织修复与再生分会. 中国糖尿病足防治指南(2019版)(Ⅰ)[J]. 中华糖尿病杂志, 2019, 11(2): 92-93, 108. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm Chinese Diabetes Society, Chinese Society of Infectious Diseases, Chinese Society for Tissue Repair and Regeneration. Chinese guideline on prevention and management of diabetic foot (2019 edition)(I)[J]. Chinese Journal of Diabetes Mellitus, 2019, 11(2): 92-93, 108. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm
[18]	吴景竹, 侯旭宏, 曹建文, 等. 上海糖尿病患者经济负担的深度访谈报告[J]. 医学与哲学(B), 2018, 39(8): 93-97. https://www.cnki.com.cn/Article/CJFDTOTAL-YXZL201808029.htm WU J Z, HOU X H, CAO J W, et al. Economic burden of diabetes in Shanghai: an in-depth interview report[J]. Medicine & Philosophy, 2018, 39(8): 93-97. https://www.cnki.com.cn/Article/CJFDTOTAL-YXZL201808029.htm
[19]	王爱红, 许樟荣, 纪立农. 中国城市医院糖尿病截肢的临床特点及医疗费用分析[J]. 中华医学杂志, 2012, 92(4): 224-227. WANG A H, XU Z R, JI L N. Clinical characteristics and medical costs of diabetics with amputation at central urban hospitals in China[J]. National Medical Journal of China, 2012, 92(4): 224-227.
[20]	BOODOO C, PERRY J A, LEUNG G, et al. Cost-effectiveness of telemonitoring screening for diabetic foot ulcer: a mathematical model[J]. CMAJ Open, 2018, 6(4): E486-E494.
[21]	中华医学会糖尿病学分会, 中华医学会感染病学分会, 中华医学会组织修复与再生分会. 中国糖尿病足防治指南(2019版)(Ⅳ)[J]. 中华糖尿病杂志, 2019, 11(5): 316-317, 327. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm Chinese Diabetes Society, Chinese Society of Infectious Diseases, Chinese Society for Tissue Repair and Regeneration. Chinese guideline on prevention and management of diabetic foot (2019 edition) (Ⅳ)[J]. Chinese Journal of Diabetes Mellitus, 2019, 11(5): 316-317, 327. https://www.cnki.com.cn/Article/CJFDTOTAL-HBYX201911002.htm
[22]	上海市统计局. 2019年上海市国民经济和社会发展统计公报[EB/OL]. (2020-03-09)[2021-02-05]. http://tjj.sh.gov.cn/tjgb/20200329/05f0f4abb2d448a69e4517f6a6448819.html. Shanghai Municipal Bureau of Statistics. 2019 Shanghai Statistical Bulletin of National Economic and Social Development[EB/OL]. (2020-03-09)[2021-02-05]. http://tjj.sh.gov.cn/tjgb/20200329/05f0f4abb2d448a69e4517f6a6448819.html.
[23]	张晓梅, 许樟荣, 冉兴无, 等. 中国2型糖尿病下肢动脉病变的筛查研究: China-DiaLEAD研究临床意义与结果解读[J]. 中华糖尿病杂志, 2020, 12(11): 870-873. https://www.cnki.com.cn/Article/CJFDTOTAL-SHEY201709008.htm ZHANG X M, XU Z R, RAN X W, et al. Screening study of lower extremity arterial disease in type 2 diabetes mellitus in China: clinical significance and result interpretation of China-DiaLEAD study[J]. Chinese Journal of Diabetes Mellitus, 2020, 12(11): 870-873. https://www.cnki.com.cn/Article/CJFDTOTAL-SHEY201709008.htm