胆脂瘤手术中保留外耳道后壁鼓室成形术联合与不联合填塞的成本效益分析

文献信息

中文摘要

目的： 从医疗支付方角度，确定胆脂瘤手术中骨性填塞鼓室成形术与不联合填塞的保留外耳道后壁技术相比的成本效益。
研究设计： 状态转换马尔可夫模型。
研究场所： 荷兰一家三级医疗中心。
方法： 开发了一个状态转换马尔可夫模型，以评估5年时间范围内的成本和健康结局。健康获益以质量调整生命年量化。所有成本均以欧元表示。转移概率和并发症发生率来自一项倾向评分匹配的回顾性队列研究（n=110耳）。匹配变量包括胆脂瘤起源、根据STAM分类的疾病范围以及既往中耳手术。进行了确定性单因素敏感性分析和概率敏感性分析。
结果： 该模型估算了40岁患者接受骨性填塞鼓室成形术或不联合乳突填塞的保留外耳道后壁技术的5年成本和健康结局。骨性填塞鼓室成形术导致更高的平均成本（5954欧元 vs 4844欧元），主要由更长的手术时间驱动。然而，它在5年内也产生了更多的质量调整生命年（2.76 vs 2.47）。这对应于每增加一个质量调整生命年获得3855欧元的增量成本效益比，远低于普遍接受的支付意愿阈值。概率敏感性分析证实了这些发现的稳健性，表明在50000欧元支付意愿下，骨性填塞鼓室成形术在97%的模拟中具有成本效益。
结论： 骨性填塞鼓室成形术是胆脂瘤手术中不联合乳突填塞的保留外耳道后壁技术的一种具有成本效益的替代方案，应在手术规划中予以考虑。

英文摘要

OBJECTIVE: To determine the cost-effectiveness of the bony obliteration tympanoplasty compared with canal wall up without obliteration in cholesteatoma surgery from a healthcare payer perspective.
STUDY DESIGN: State-transition Markov model.
SETTING: Tertiary care center in the Netherlands.
METHODS: A state-transition Markov model was developed to evaluate costs and health outcomes over a 5-year time horizon. Health benefits were quantified in quality-adjusted life years. All costs were expressed in euros. Transition probabilities and complication rates were derived from a propensity score-matched retrospective cohort study (n = 110 ears). Matching variables included cholesteatoma origin, disease extent according to the STAM classification, and prior middle ear surgery. Deterministic one-way sensitivity analyses and probabilistic sensitivity analyses were conducted.
RESULTS: The model estimated 5‑year costs and health outcomes for a 40‑year‑old patient undergoing either bony obliteration tympanoplasty or the canal wall up technique without mastoid obliteration. Bony obliteration tympanoplasty resulted in higher mean costs (€5954 vs €4844), mainly driven by longer operative time. However, it also yielded more quality-adjusted life years over 5 years (2.76 vs 2.47). This corresponded to an incremental cost-effectiveness ratio of €3855 per additional quality-adjusted life year gained, which is well below commonly accepted willingness-to-pay thresholds. Probabilistic sensitivity analysis confirmed the robustness of these findings, indicating that bony obliteration tympanoplasty is cost-effective in 97% of simulations at a willingness-to-pay of €50,000.
CONCLUSION: Bony obliteration tympanoplasty is a cost-effective alternative to the canal wall up technique without mastoid obliteration for cholesteatoma surgery and should be considered in surgical planning.