游离腓骨瓣在修复口腔癌患者下颌骨连续性中的成本与效果分析
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摘要
目的通过结合术后生存率、花费以及健康效用,在术后整个生命周期内评价腓骨重建的成本与效果,为患者及医生提供更为明确的决策基础,为医疗政策制定者分配医疗资源提供理论依据。方法成本-效果分析是基于Markov模型,将术后患者分为4种Markov状态:无疾病的,被救治的,远处转移的以及死亡的,通过Markov状态间的转换概率来拟合生存曲线,同时为每个Markov状态赋予相应的花费以及健康效用。游离腓骨重建下颌连续性与不重建的比较是通过增量成本效果比。模型的稳定性检验是基于蒙特卡洛模拟的概率敏感性分析。结果队列分析发现在整个生命周期,腓骨重建下颌连续性以多付出32 659 CNY的代价获得了0.33质量调整生命年的改善。概率敏感性分析发现,患者的支付意愿影响了手术方案的选择,超过99 075 CNY/QAL的支付意愿是选择重建的基础。结论游离腓骨重建下颌连续性以更高的花费获得更高的生存质量改善,因而患者的支付意愿影响着医疗决策,当支付意愿超过99 075 CNY/QALY时,重建是值得推荐的。
Objective To elucidate to what extend reconstruction with free fibula flap is preferred over non-reconstruction by combining costs, health utility and oncological outcomes together, so as to help the patients to make the wiser decision and the policy makers to achieve the better medical resource allocation.Methods The cost-effective analysis was based on Markov model, simulating the whole process after surgery. The patients were grouped into four Markov states: no evidence of disease, salvaged, metastases and dead. The state of transition probabilities and health utility were derived from literature. The costs were collected from the institutional data. The comparison of reconstruction with free fibula flap versus non-reconstruction was measured by incremental cost-effective ratios. The stability of the model was checked by probabilistic sensitivity analysis with Monte Carlo simulation.Results The base case analysis found that over a life time, the mandibular reconstructionimproved 0.33 qualityadjustedlifeyear(QALY)with32659 Chineseyang(CNY).Intheprobabilisticsensitivity analysis, the patients' willingness-to-pay(WTP) played an important role in the acceptance of surgery, and the changing point was 99 075 CNY.Conclusion The reconstruction of mandibular continuity brings more effectiveness with more costs, so WTP of the patients plays a role in decision making. When WTP over 99 075 CNY, the reconstruction of mandibular continuity may be choice of treatment.
Objective To elucidate to what extend reconstruction with free fibula flap is preferred over non-reconstruction by combining costs, health utility and oncological outcomes together, so as to help the patients to make the wiser decision and the policy makers to achieve the better medical resource allocation.Methods The cost-effective analysis was based on Markov model, simulating the whole process after surgery. The patients were grouped into four Markov states: no evidence of disease, salvaged, metastases and dead. The state of transition probabilities and health utility were derived from literature. The costs were collected from the institutional data. The comparison of reconstruction with free fibula flap versus non-reconstruction was measured by incremental cost-effective ratios. The stability of the model was checked by probabilistic sensitivity analysis with Monte Carlo simulation.Results The base case analysis found that over a life time, the mandibular reconstructionimproved 0.33 qualityadjustedlifeyear(QALY)with32659 Chineseyang(CNY).Intheprobabilisticsensitivity analysis, the patients' willingness-to-pay(WTP) played an important role in the acceptance of surgery, and the changing point was 99 075 CNY.Conclusion The reconstruction of mandibular continuity brings more effectiveness with more costs, so WTP of the patients plays a role in decision making. When WTP over 99 075 CNY, the reconstruction of mandibular continuity may be choice of treatment.
引文
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[29] Ishida S,Shibuya Y,Kobayashi M,et al. Assessing stomatognathic performance after mandibulectomy according to the method of mandibular reconstruction[J].Int J Oral Maxillofac Surg,2015,44(8):948-955.
[30] Sher DJ,Tishler RB,Annino D,et al. Cost-effectiveness of CT and PET-CT for determining the need for adjuvant neck dissection in locally advanced head and neck cancer[J].Ann Oncol,2010,21(5):1072-1077.
[31] de Almeida JR,Moskowitz AJ,Miles BA,et al. Cost-effectiveness of transoral robotic surgery versus(chemo)radiotherapy for early T classification oropharyngeal carcinoma:a cost-utility analysis[J].Head Neck,2016,38(4):589-600.
[32] Ubilava D,Foster KA,Lusk JL,et al. Effects of income and social awareness on consumer WTP for social product attributes[J].Techonl Forecast Soc Change,2010,77(4):587-593.
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[34] Wan Q,Zwahlen RA,Cheng G,et al. Influence of mandibular reconstruction on patients'health-related quality of life[J].J Oral Maxillofac Surg,2011,69(6):1782-1791.
[35] Ojo B,Genden EM,Teng MS,et al. A systematic review of head and neck cancer quality of life assessment instruments[J].Oral Oncol,2012,48(10):923-937.
[2] Urken ML,Buchbinder D,Weinberg H,et al. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient:a comparative study of reconstructed and nonreconstructed patients[J].Laryngoscope,2015,125(7):1512.
[3] Okoturo E,Ogunbanjo O,Akinleye A,et al. Quality of life of patients with segmental mandibular resection and immediate reconstruction with plates[J].J oral Maxilofac Surg,2011,69(8):2253-2259.
[4] Maciejewski A,Szymczyk C.Fibula free flap for mandible reconstruction:analysis of 30 consecutive cases and quality of life evaluation[J].J Reconstr Microsurg,2007,23(1):1-10.
[5] Zavalishina L,Karra N,Zaid WS,et al. Quality of life assessment in patients after mandibular resection and free fibula flap reconstruction[J].J Ooral Maxilofac Surg,2014,72(8):1616-1626.
[6] Kelly MP,Heath I,Howick J,et al. The importance of values in evidence-based medicine[J].BMC Med Ethics,2015,16(1):69.
[7] Tei K,Totsuka Y,Iizuka T,et al. Marginal resection for carcinoma of the mandibular alveolus and gingiva where radiologically detected bone defects do not extend beyond the mandibular canal[J]. J Ooral Maxilofac Surg,2004,62(7):834-839.
[8] Hao SP,Tsang NM,Chang KP,et al. Treatment of squamous cell carcinoma of the retromolar trigone[J].Laryngoscope,2006,116(6):916-920.
[9] Shaha AR,Spiro RH,Shah JP,et al. Squamous carcinoma of the floor of the mouth[J].AM J Surg,1984,76(3):492.
[10] Totsuka Y,Usui Y,Tei K,et al. Results of surgical treatment for squamous carcinoma of the lower alveolus:segmental vs. marginal resection[J].Head Neck,1991,13(2):114-120.
[11] Wald RM Jr,Calcaterra TC.Lower alveolar carcinoma:segmental v marginal resection[J].Arch Otolaryngol,1983,109(9):578-582.
[12] Wolff D,Hassfeld S,Hofele C. Influence of marginal and segmental mandibular resection on the survival rate in patients with squamous cell carcinoma of the inferior parts of the oral cavity[J].J Cranio Maxillofac Surg,2004,32(5):318-323.
[13] Dubner S,Heller KS. Local control of squamous cell carcinoma following marginal and segmental mandibulectomy[J].Head Neck,2010,15(1):29-32.
[14] Byers RM,Anderson B,Schwarz EA,et al. Treatment of squamous carcinoma of the retromolar trigone[J].Am J Clin Oncol,1984,7(6):647-652.
[15] Mu?oz Guerra MF,Naval Gías L,Campo FRg,et al. Marginal and segmental mandibulectomy in patients with oral cancer:a statistical analysis of 106 cases[J].J Oral Maxil Surg,2003,61(11):1289-1296.
[16] O'Brien CJ,Adams JR,McNeil EB,et al. Influence of bone invasion and extent of mandibular resection on local control of cancers of the oral cavity and oropharynx[J].Int J Oral Maxillofac Surg,2003,32(5):492-497.
[17] Nomura T,Shibahara T,Cui NH,et al. Patterns of mandibular invasion by gingival squamous cell carcinoma[J].J Oral Maxillofac Surg,2005,63(10):1489-1493.
[18] Shingaki S,Nomura T,Takada M,et al. Squamous cell carcinomas of the mandibular alveolus:analysis of prognostic factors[J].Oncology,2002,62(1):17-24.
[19] Wong LY,Wei WI,Lam LK,et al. Salvage of recurrent head and neck squamous cell carcinoma after primary curative surgery[J].Head Neck,2003,25(11):953-959.
[20] Matoscevic K,Graf N,Pezier TF,et al. Success of salvage treatment a critical appraisal of salvage rates for different subsites of HNSCC[J].Otolaryng Head Neck,2014,151(3):454-461.
[21] Vermorken JB.Medical treatment in head and neck cancer[J].Ann Oncol,2005,16(Suppl 2):258-264.
[22] Rivera F,García-Casta?o A,Vega N,et al.Cetuximab in metastatic or recurrent head and neck cancer:the extreme trial[J]. Expert Rev Anticanc Ther,2009,9(10):1421-1428.
[23] Johnson D.The triangular distribution as a proxy for the beta distribution in risk analysis[J].JRStatSoc,1997,46(3):387-398.
[24]简伟研,卢铭,乔丽娜,等.北京市恶性肿瘤放疗病例医疗费用分析[J].中国医院管理,2010,30(2):62-63.
[25]杨金娟,高建民,许永建,等.恶性肿瘤化疗患者住院费用构成及影响因素分析[J].中国卫生经济,2014,33(9):35-38.
[26]曹海涛,王俊琪,施永兴.五省市注册临终关怀机构晚期恶性肿瘤患者的医疗费用调查[J].中国全科医学,2010,13(31):3544-3546.
[27]黄悦勤.临床流行病学[M].第4版.北京:人民卫生出版社,2013:19-20.
[28] Peisker A,Raschke GF,Guentsch A,et al. Longterm quality of life after oncologic surgery and microvascular free flap reconstruction in patients with oral squamous cell carcinoma[J]. Med Oral Patol Oral Cir Bucal,2016,21(4):e420-e424.
[29] Ishida S,Shibuya Y,Kobayashi M,et al. Assessing stomatognathic performance after mandibulectomy according to the method of mandibular reconstruction[J].Int J Oral Maxillofac Surg,2015,44(8):948-955.
[30] Sher DJ,Tishler RB,Annino D,et al. Cost-effectiveness of CT and PET-CT for determining the need for adjuvant neck dissection in locally advanced head and neck cancer[J].Ann Oncol,2010,21(5):1072-1077.
[31] de Almeida JR,Moskowitz AJ,Miles BA,et al. Cost-effectiveness of transoral robotic surgery versus(chemo)radiotherapy for early T classification oropharyngeal carcinoma:a cost-utility analysis[J].Head Neck,2016,38(4):589-600.
[32] Ubilava D,Foster KA,Lusk JL,et al. Effects of income and social awareness on consumer WTP for social product attributes[J].Techonl Forecast Soc Change,2010,77(4):587-593.
[33] Shiroiwa T,Sung YK,Fukuda T,et al. International survey on willingness-to-pay(WTP)for one additional QALY gained:what is the threshold of cost effectiveness?[J].Health Econ,2010,19(4):422-437.
[34] Wan Q,Zwahlen RA,Cheng G,et al. Influence of mandibular reconstruction on patients'health-related quality of life[J].J Oral Maxillofac Surg,2011,69(6):1782-1791.
[35] Ojo B,Genden EM,Teng MS,et al. A systematic review of head and neck cancer quality of life assessment instruments[J].Oral Oncol,2012,48(10):923-937.