Systematic review of cost-effectiveness research of stroke evaluation and treatment.
Systematic review of cost-effectiveness research of stroke evaluation and treatment.
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中风评估和治疗的成本效益研究的系统回顾。
DOI：
10.1161/01.str.30.12.2759
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发表时间：
1999
期刊：
影响因子：
8.3
通讯作者：
Shah Ebrahim
中科院分区：
文献类型：
--
作者：
Shah Ebrahim
致编辑：霍洛威及其同事对卒中评估和治疗的成本效益研究的回顾1可能无意中引入了纳入研究的选择标准的主要偏倚。他们决定只纳入那些使用质量调整生命年（Qs）作为健康影响指标的研究。未给出该标准的依据。通过这样做，使用挽救生命或避免中风等指标的成本效益研究被排除在外，作者没有提供关于研究排除的信息，以允许读者评估产生的潜在偏倚。该评论在两个方面存在偏见。首先，在许多卒中评估和管理领域，诊断准确性、患者满意度或症状减轻的测量是相关的，使用QURs是不合适的。值得注意的是，该综述排除了对卒中管理最有效的干预措施--有组织的卒中护理和康复--的考虑，对这一干预措施进行了成本效益研究的综述。2，3因此，该综述在描述卒中成本效益研究的范围时存在偏见。第二，审查对成本效益作出了有偏差的估计。为了说明这种偏倚，考虑非瓣膜性房颤患者的抗凝治疗。他们提出的成本效益研究表明，华法林在高风险和中等风险患者中占主导地位，但在低风险患者中，每QALY的成本非常高。作者得出结论，抗凝是除低风险患者外所有患者的首选。一项比较仅抗凝、抗凝或阿司匹林或仅阿司匹林的成本效益研究报告了预防卒中的成本，但该研究被排除在外，但得出了明显不同的结论。4在这项研究中，单用阿司匹林治疗方案预防卒中的成本（对大多数患者和医生来说，这可能是一个比QALY更相关的结局）显著降低，为1300美元（表）。最有效的治疗方法是对那些能够耐受的人进行抗凝治疗，对其余的人使用阿司匹林，因为如果并发症较低，每年可以预防1300例中风，即使并发症很高，也可以预防更多的中风，而不是简单地给每个人服用阿司匹林-但这种方法忽略了抗凝治疗的较高成本。如果抗凝治疗的并发症很高，这往往是在老年患者的情况下，阿司匹林唯一的政策是最具成本效益的选择。我希望这篇综述的作者能考虑通过使用更合适的纳入标准来更新它，从而得出更相关的决定，以帮助临床医生和政策制定者。
To the Editor: Holloway and colleagues’ review of cost-effectiveness studies in stroke evaluation and treatment 1 may have inadvertently introduced major biases by the selection criteria used for inclusion of studies. They decided to include only studies that used quality-adjusted life-years (QALYs) as the indicator of health effect. The justification for this criterion is not given. By doing this, cost-effectiveness studies that used indicators such as lives saved or strokes avoided are excluded, and the authors do not provide information on study exclusions to allow the reader to assess the potential bias created. The review is biased in two ways. First, the use of QALYs is inappropriate in many areas of stroke evaluation and management where measures of diagnostic accuracy, patient satisfaction, or reduction in symptoms are of relevance. It is noteworthy that the review excluded consideration of the most effective intervention for stroke management—organized stroke care and rehabilitation—for which reviews of cost-effectiveness studies have been performed. 2,3 Thus, the review is biased in describing the range of cost-effectiveness studies in stroke. Second, the review provides biased estimates of costeffectiveness. To illustrate this bias, consider the use of anticoagulation for patients with nonvalvular atrial fibrillation. The cost-effectiveness studies they present show that warfarin dominates among highand medium-risk patients but in low-risk patients has a very high cost per QALY. The authors concluded that anticoagulation was the preferred option for all but the low-risk patients. A cost-effectiveness study comparing anticoagulation only, anticoagulation or aspirin, or aspirin only that reported cost per stroke prevented was excluded but comes to remarkably different conclusions. 4 In this study, the cost per stroke prevented (which may arguably be a more relevant outcome than a QALY to most patients and doctors) was substantially lower for the aspirin-only regimen at US$1300 (Table). The most effective treatment is anticoagulation for those who can tolerate it and aspirin for the remainder, as this prevents 1300 strokes a year if complications are low, and even in complications are high still prevents more strokes than simply giving everyone aspirin— but this approach ignores the higher costs involved in anticoagulation. If complications of anticoagulation are high, which tends to be the case in older patients, the aspirin only policy is the most cost-effective option. I hope the authors of this review will consider updating it by using more appropriate inclusion criteria and thereby arriving at more relevant decisions to aid clinicians and policy makers.
影响因子：
158.5
作者：
Gott, VL;Greene, PS;Pyeritz, RE
通讯作者：
Pyeritz, RE
影响因子：
158.5
作者：
Wiebers, D;Whisnant, J;Kivisaari, R
通讯作者：
Kivisaari, R
动脉瘤性蛛网膜下腔出血的转诊偏倚。
影响因子：
4.1
作者：
Whisnant,JP;Sacco,SE;O'Fallon,WM;Fode,NC;SundtJr,TM
通讯作者：
SundtJr,TM