THE COST-EFFECTIVENESS OF STEREOTAXIC RADIOSURGERY VERSUS SURGICAL RESECTION IN THE TREATMENT OF SOLITARY METASTATIC BRAIN-TUMORS
THE COST-EFFECTIVENESS OF STEREOTAXIC RADIOSURGERY VERSUS SURGICAL RESECTION IN THE TREATMENT OF SOLITARY METASTATIC BRAIN-TUMORS
复制标题
DOI：
10.1227/00006123-199509000-00012
复制
发表时间：
1995-09-01
期刊：
影响因子：
4.8
通讯作者：
GREEN, M
中科院分区：
文献类型：
--
作者：
RUTIGLIANO, MJ;LUNSFORD, LD;GREEN, M
孤立性转移性脑肿瘤是神经外科医生最常见的颅内肿瘤。手术切除脑转移瘤联合全脑放疗（WBR）较单纯全脑放疗显著提高患者生存率。立体定向放射外科（SR）似乎提供的结果类似于手术切除。为了分析这些不同治疗方法的经济效益，我们比较了1974年至1994年医学文献中报道的手术切除和SR的结果。我们纳入了以下研究：1)至少75%的患者接受了WBR；2)研究时间为计算机断层扫描时代（1975年以后）；3)报告手术发病率、死亡率和中位生存期；4)研究日期未包括在最近的更新或综述中；5)报告肿瘤组织学；6)钴-60伽马单元用于SR。3项手术切除研究和1项SR研究符合所有入组要求。WBR基线由两项前瞻性随机试验建立，并用于增量成本效益分析。我们开发了一个典型的资源使用模型，用于简单的手术，报告的并发症，以及随后的开颅手术（复发性肿瘤或放射性坏死）两种治疗方案。使用1999年医疗保险提供者分析和审查数据库，使用手术和WBR的平均成本：收费比，从社会角度估计成本。对五个地点的资金和操作成本进行了调查，用于放射外科手术。我们的分析显示放射手术具有较低的无并发症手术成本（20,209美元对27,587美元），较低的每例平均并发症成本（2,534美元对2,874美元），较低的每次手术总成本（22,743美元对30,461美元），更具成本效益（24,811美元对32,149美元/生命年），并且具有更好的增量成本效益（40,648美元对52,384美元/生命年）。敏感性分析显示，要改变分析结果，需要对关键假设进行重大修改。平衡两种治疗的增量成本效益需要以下条件之一：1)SR年病例量减少38.7%,2)SR手术成本增加34.7%,3)手术切除成本减少18.8%,4)SR发病率成本增加240.5%,5)SR中位生存期减少12.7%,6)手术切除中位生存期增加16.8%。消除所有手术切除的发病率成本仍然会导致SR的成本效益增加。这些结果表明，有必要进行前瞻性临床试验，以检查手术切除和SR治疗孤立性转移性脑肿瘤的临床疗效和成本效益。
SOLITARY METASTATIC BRAIN tumors are the most common intracranial neoplasms encountered by neurosurgeons. Surgical resection of brain metastasis with whole brain radiotherapy (WBR) significantly increases survival in comparison with WBR alone. Stereotactic radiosurgery (SR) seems to provide results that are similar to those of surgical resection. To analyze the economic efficiency of these different treatments, we compared the results of surgical resection and SR as reported in the medical literature between 1974 and 1994. We included studies in which: 1) at least 75% of patients received WBR; 2) study dates were in the computed tomography era (after 1975); 3) operative morbidity, mortality, and median survival were reported; 4) study dates were not included in a more recent update or review; 5) tumor histologies were reported; and 6) the cobalt-60 gamma unit was used for SR. Three surgical resection studies and one SR study met all entry requirements. The WBR baseline was developed from two prospective, randomized trials and used for incremental cost effectiveness analysis. We developed a model of typical resource usage for uncomplicated procedures, reported complications, and subsequent craniotomies (for recurrent tumor or radiation necrosis) for both treatment options. Costs were estimated from the societal viewpoint using the 1999 Medicare Provider Analysis and Review database with average cost:charge ratios for surgery and WBR. A survey of capital and operating costs from five sites was used for radiosurgery. Our analysis revealed that radiosurgery had a lower uncomplicated procedure cost ($20,209 versus $27,587), a lower average complication cost per case ($2,534 versus $2,874), and a lower total cost per procedure ($22,743 versus $30,461), was more cost effective ($24,811 versus $32,149 per life year), and had a better incremental cost effectiveness ($40,648 versus $52,384 per life year) than surgical resection. A sensitivity analysis revealed that large changes in key assumptions would be required to change the analysis outcome. Equalization of the incremental cost effectiveness of the two treatments would require one of the following: 1) a 38.7% reduction in SR annual case volume, 2) a 34.7% increase in SR procedure cost, 3) a 18.8% reduction in surgical resection procedure cost, 4) a 240.5% increase in SR morbidity cost, 5) a 12.7% reduction in SR median survival, 6) a 16.8% increase in surgical resection median survival. Elimination of all surgical resection morbidity cost would still result in superior incremental cost effectiveness for SR. These results indicate the need for prospective clinical trials that examine both the clinical efficacy and the cost effectiveness of surgical resection and SR in the management of solitary metastatic brain tumors.