以血栓溶解劑治療缺血性中風成本效益分析

Abstract

背景與目的—本研究評估臺大醫院新竹分院以靜脈注射血栓溶解劑治療急性缺血性中風成效與成本效益分析。 研究方法—比較2006至2012年期間因急性缺血性中風入院而接受經靜脈注射血栓溶解劑治療，和經過配對的對照組療效與安全性。主要療效指標為於出院後第三個月，病人的生活功能獨立能力。安全指標為有症狀的顱內出血及住院期間死亡率。健康結果以調整品質後存活人年（quality-adjusted life years, QALYs）計算，成本以住院醫療費用評估。成本效益比為兩組費用差距除以兩組QALY差距。 結果— 54位患者接受血栓溶解劑治療及54位對照組納入研究。血栓溶解劑組與對照組比較，發病後三個月回復獨立生活能力分別為33.33%及18.52 % （P= 0.079），住院死亡率無差異，有症狀腦出血與血栓溶解劑顯著相關，平均住院費用 (137410 點比110618 點，P=0.224)無差異。計算使用血栓溶解劑成本效益比，每多花19412.85元可以拯救額外的一個QALY。 結論— 臺大醫院新竹分院靜脈注射血栓溶解劑治療急性腦梗塞結果顯示有效且安全。靜脈注射血栓溶解劑治療急性腦梗塞短期不能節省醫療費用，但長期預後較佳，相對可節省醫療支出。經成本效益研究的公共衛生政策可讓血栓溶解劑治療缺血性中風效益最大化。

Background and Purpose—The aim of this study was to assess the efficacy and cost-effectiveness of intravenous tissue plasminogen activator for acute ischemic stroke in National Taiwan University Hospital Hsinchu branch. Methods—The outcome of acute ischemic stroke patients treated with intravenous tissue plasminogen activator between 2006 and 2012 was compared to those admitted who were treated by conservative treatment. Primary outcome was functional independence at 3 months. Safety outcomes were symptomatic intracranial hemorrhage and in-hospital mortality. Health benefits were measured in quality-adjusted life-years (QALYs). The economic outcome was the difference in healthcare costs between the 2 treatment alternatives. The incremental cost-effectiveness ratio was calculated by dividing the cost difference by the difference in QALYs. Results—A total of 54 thrombolysis and 54 non-thrombolysis patients were included. Thirty-three percent of the thrombolysis group achieved functional independence compared to 18.52 % of non-thrombolysis group (P=0.079) without significant increase in-hospital mortality. Symptomatic intracranial hemorrhage increased in thrombolysis group. The administration of tPA compared with standard medical therapy, yielding an incremental cost-effectiveness ratio of NTD 19412.85 per QALY. Conclusions—Intravenous tissue plasminogen activator for acute ischemic stroke seems efficacious and safe. Patients who received thrombolysis had better outcomes compared to non-thrombolysis cohort. Acute thrombolysis treatment might not be cost-saving in the short term compared with conservative treatment. In the long term, there are potentially large-scale health economic cost savings. Further cost-effectiveness research and the development of a public health strategy are warranted to optimize the use of tPA in Taiwan.