Screening for thalassemia: an economics viewpoint.
Screening for thalassemia: an economics viewpoint.
复制标题
地中海贫血筛查：经济学观点。
DOI：
--
复制
发表时间：
1997
期刊：
影响因子：
--
通讯作者：
K. Indaratna
中科院分区：
文献类型：
--
作者：
K. Indaratna
地中海贫血给个人、社会和经济带来负担：一个关键问题是医学和经济观点是否一致。使用精确的分子探针，可以对已知携带者的父母进行各种地中海贫血基因型的产前诊断，因为以前有患病的孩子或阳性的家庭遗传史。然而，预防第一个受影响儿童出生的理想选择需要社区筛查。唯一切实可行的办法是在产前诊所对怀孕早期的妇女进行产前检查。最初的步骤（OF， DCIP）简单，便宜，容易与标准的产前程序相结合。在第二阶段，配偶筛选，遵守是次优的，并涉及非常规的机会成本。后续步骤（阳性配对的二次筛查、阳性基因分型和胎儿诊断[PND]）对提供者和消费者来说成本更高，而且，由于它们相对昂贵，如果经济负担的主要部分（直接和间接成本）由消费者承担，那么每个步骤的依从性都会降低。因此，只有一部分病例可能面临是否终止妊娠的最终决定。已经对每个阶段（ANC- >PND）的成本进行了一些广泛的估计，以便与几种地中海贫血疾病类别在其预计生命周期内的病例管理估计成本进行比较，同时正在进行一些更详细的研究，以微调诊断的实际成本（直接和间接）。从纯粹的经济意义上讲，这种情况提供了考虑在利益：成本比方面在PND和疾病病例管理之间进行权衡的机会。从卫生系统的有利角度来看，这一比例在很大程度上取决于依从性，因为该系统必须考虑照顾所有地中海贫血病例的成本，包括那些本可通过最佳依从性避免的分娩。在理想的情况下，粗略的估计显示可能的效益：成本比为100亿美元，支持以社区为基础的筛查的概念。然而，这样的结果将短期有限时间内的程序（诊断）与更不可预测的、更长的生命周期（病例管理）进行了比较，后者需要官僚机构的灵活性（如果公共提供者支付）或家庭情感/财政投资（如果消费者支付）或两者兼有（成本分摊）：无论哪种方式，长期投资规划都有一个不可避免的因素，需要权衡等式中的情感、社会和财政成分。从这个意义上说，地中海贫血综合症是在家庭、社区和国家各级评估和处理慢性病负担的决策途径的一个例子：在后一级，区域发病率差别很大，这是一个地缘政治因素，可能需要不同的人口规划。
Thalassemia presents individual, social and economic burdens: a key question is whether medical and economic viewpoints converge or not. Using precise molecular probes, prenatal diagnosis of the various thalassemia genotypes is available in the case of parents who are known carriers, so identified because of a previous affected child or a positive family genetic history. However, the ideal option of prevention of the birth of a first affected child requires community screening. The only practical approach thereto is prenatal screening of women in early pregnancy at ante-natal clinics (ANC). The initial steps (OF, DCIP) are simple, cheap and easily coupled with standard prenatal procedures. In the second phase, spouse screening, compliance is suboptimal and involves non-routine opportunity costs. Subsequent steps (secondary screening of positive pairs, genotyping of positives, and fetal diagnosis [PND]) represent greater costs to provider and consumer, and, as they are relatively expensive, reduced compliance at each step if the major part of the economic burden (direct and indirect costs) is to be borne by the consumer. Thus, only a proportion of cases is likely to face the final decision to terminate pregnancy or not. Some broad estimates of costs of each phase (ANC-->PND) have been made for comparison with the estimated costs of case management of the several thalassemia disease classes for their projected lifetimes, while several more detailed studies are in progress to fine tune the real costs (direct and indirect) of diagnosis. In a purely economic sense the situation presents opportunity to consider trade-offs between PND and disease case management, in terms of benefit:cost ratio. Viewed from a health systems vantage point this ratio depends substantially on compliance, as the system must consider the cost of caring for all thalassemia cases, including those births which could have been avoided by optimal compliance. In ideal circumstances the rough estimates indicate a probable benefit:cost ratio > 1, supporting the notion of community-based screening. Such a result, however, compares procedures in a short, finite time frame (diagnosis) with a less predictable, longer life-time (case management), requiring bureaucratic flexibility (if the public provider is to pay) or family emotional/fiscal investment (if the consumer is to pay) or both (cost-sharing): either way there is an inescapable element of long term investment planning that requires squaring off of the emotional, social and fiscal ingredients in the equation. In this sense the thalassemia syndromes represent an example of decision-making pathways involved in assessing and handling chronic disease burdens at family, community and national levels: at the latter level regional incidence varies considerably, a geopolitical factor which may require differential demographic planning.