心臟超音波篩檢推動對學童心因性猝死疾病防治之效果與成本分析

Abstract

研究背景： 潛在性心臟血管疾病經常是學童猝死的主要原因。如能早期發現具有猝死風險的學童及青少年才是預防心因性猝死的主要方法，但目前早期發現仍是一大挑戰。心臟超音波是診斷結構性心臟血管疾病異常的主要工具，但大型心臟超音波的取得有限及價格高，使得心臟超音波作為學童心臟篩檢的主要工具受到限制。經由手攜式超音波的進步，使得學童在校接受心臟超音波篩檢成為可行

研究目的： 評估應用手攜式心臟超音波篩檢以早期發現結構性心臟病的效率及作為防範心因性猝死的成本費用分析。

材料與方法： 本研究於2001年至2010年由台中縣政府資助，為每位國小及國中入學新生作心臟疾病篩檢計畫，使用手攜式心臟超音波儀器作為篩檢學童結構性心臟血管疾病的第一線診斷工具。結構性心臟病分為三大類型，分別為：出生時曾立即對生命具有威脅（如：發紺或心臟衰竭）必須或已接受治療並需定期追蹤、有明顯臨床表徵（如：心雜音、發紺）且未來可能具有生命威脅，及延遲診斷且具有高生命威脅風險類型。進行評估心臟超音波篩檢之成果並與常規理學心臟疾病篩檢進行效果分析與成本費用比較。

研究結果： 十年共347,554名新生學童接受手攜式心臟超音波篩檢結構性心臟病，盛行率為每十萬名1,780例個案，而常規性理學檢查僅發現每十萬名381例個案。三大類型中，常規性理學篩檢及心臟超音波篩檢盛行率分別為0.65% vs 0.67%、3.10% vs 6.58% 及0.05% vs 0.82%。延遲診斷且具有高生命威脅的結構性心臟病，約每十萬人中有82.28名，其中94.27%在使用心臟超音波後才被發現；整體學童中有54.63%為心臟超音波新發現的個案；篩檢每位學童平均費用中，手攜式心臟超音波篩檢較常規理學檢查多花費205元，但每發現一名病例的平均費用約需60,685元，較常規理學檢查發現病例費用減少14,336元。尤其在延遲診斷且具有高生命威脅風險的類型中，單一病例平均診斷費用，心臟超音波篩檢反而只需要常規理學篩檢費用的10%。而十年心臟篩檢中，未再次發生學童心因性猝死之情形。

結論： 心臟超音波篩檢可以有效發現致命危險性的心臟病．藉由心臟超音波篩檢，早期診斷結構性心臟病不僅是防治心因性猝死的首要方法，且對減少醫療成本具有高度的成本效益價值。推動全面性心臟超音波篩檢將有如預防注射防止重大感染病一樣，可促進全民健康。

Background: Underlying cardiovascular disease is almost the main cause of sudden death in school-aged children. Prospective identifications of those children and adolescent who are at risk of sudden cardiac death (SCD) is mandatory for prevention of SCD but still a challenge. Echocardiography has been the major tool of evaluation of structural cardiovascular disease (SCVD) abnormalities. Availability and cost of platforms echocardiography have limited it as first tool for routinely screening SCVD in school-aged children. By the advancement of hand-held echocardiography (HHE), it had made screening echocardiography for SCVD feasible for school-aged children at school.

Objects: We intended to evaluate the effectiveness of screening echocardiography by HHE on early identification of SCVD and cost analysis for primary prevention of SCD

Materials & Methods: From 2001 to 2010, all enrolled new school-aged children in primary school and junior high school in Taichung County were prospectively screened for SCVD by HHE as a primary screening tool granted from the government of Taichung County. Those SCVD were classified into 3 groups; group I. those with early onset of life threatening condition (such as cyanosis or heart failure) which should be and /or have been immediately treated and under clinical follow-up, group II those with overt clinical presentations (cardiac murmur, cyanosis) and potential life-threatening in the future, group III those of delayed diagnosis with high potential of life-threatening risk. The cost-effectiveness was analyzed in comparison with conventional clinical screening alone (CCS) .

Results: The prevalence of SCVD was 1,780 per 100,000 in 347,554 school-aged children found by HHE screening echocardiography but only 381 per 100,000 by CCS. The prevalence in screening echocardiography in comparison with CCS were 0.65‰ vs 0.67‰ in group I, 3.10‰ vs 6.58‰ in group II and 0.05‰ vs 0.82‰ in group III, respectively. Group III with delayed diagnosis of SCVD of high potential of SCD was about 82.28 cases per 100,000 with high finding rate of 94.27%. Among all children, 54.63 % were newly diagnosed by HHE. The average incremental cost for each student by HHE more than CCS was NT205. The average cost of each SCVD case by HHE was NT60,685, which was NT14,336 less than CCS, but in group III with very high potential risk of SCD, Screening echocardiography made the reduction of cost in diagnosis of each case to only 10 % of CCS. During these 10 years follow-up, no any case of SCD in school was found again.

Conclusion: Screening echocardiography was effective in identifying potentially lethal heart disorders. Early diagnosis of SCVD by screening echocardiography is not only crucial for primary prevention of SCD, but also had high cost-effectiveness in reduction of medical care cost. Screening echocardiography has important implications for public health to prevent SCD just as vaccination in prevention of major infectious diseases.