Cost Utility Analysis of Screening for Diabetic Retinopathy by a Computerized Simulation Model

(1)成本效用分析为评价糖尿病视网膜病变定期检查的效率，构建了马尔可夫决策分析模型，比较了4种检测策略：6个月、12个月、24个月、36个月的间隔筛查。临床对生活质量的影响以质量调整寿命年(QALYs)表示。费用是从日本医疗保险系统的医疗费用清单中估计出来的。我们的模型表明，筛查策略将减少视力损失并提高个体的生活质量，6个月间隔策略的增量成本-效果比为4,571,800日元/QALY，而12个月间隔策略的增量成本-效果比为662,100日元/QALY。不仅从保险公司的角度，而且从社会的角度进行评估，对于适当地评估效率是必要的。(2)糖尿病患者的主观健康价值我们调查了d-…住院患者对当前健康状态的偏好采用评定量表(RS)和标准赌博量表(SG)对糖尿病患者进行评分，并评价其实用价值与其他指标的关系。年龄、糖尿病病程与RS评分有关。糖化血红蛋白水平、糖尿病并发症和每日胰岛素注射等糖尿病状态对RS评分和SG评分均无影响。那些希望延长寿命而不是缓解疼痛的人比那些不想要的人提供了显著更高的RS分数。在人格因素中，通过因子分析从人格问卷中提取的“稳重”和“放弃倾向”与SG得分呈负相关。目前糖尿病患者的主观健康值差异很大，与他们的糖尿病状态没有很好的关系。在糖尿病的临床实践中，不仅要有客观的临床指标，还要有糖尿病状态的主观健康值，充分融入到临床决策过程中。较少

( 1 ) Cost utility analysisTo assess the efficiency of the periodic examinations of detecting diabetic retinopathy, a Markov decision analytic model was constructed to compare four detecting strategies : 6-, 12-, 24-, 36-month interval screenings. The clinical effect on quality of life was expressed as quality-adjusted life years (QALYs). The costs were estimated from medical charge lists of the health insurance system in Japan. Our model showed that screening strategies would reduce visual loss and improve quality of life in individuals and that the incremental cost-effectiveness ratio of 6-month interval strategy, 4,571,800 yen/QALYs, would be very high compared with 12-month interval strategy, 662,100 yen/QALYs. The estimation not only from insurer's viewpoint but also from societal viewpoint is necessary to the appropriate evaluation of the efficiency.( 2 ) Subjective health values of diabetic patientsWe examined preferences for current health states in hospitalized patients with d … More iabetes using the rating scale (RS) and the standard gamble (SG), and evaluated the relation between their utility values and the other characteristics. Age and diabetes duration were related to the RS scores. Diabetic states such as glycosylated hemoglobin levels, diabetic complications and daily insulin injections did not influence both the RS scores and the SG scores. The individuals who desired to extend their life rather than to relieve pain provided significant higher RS scores than those who did not desire. Of personality factors, extracted from personality questionnaires by factor analysis, the "steadiness" correlated modestly and "tendency to give up" correlated inversely with the SG scores. Current subjective health values among diabetic patients varied widely and did not relate well to their diabetic states. In clinical practice of diabetes, not only objective clinical indicators but also subjective health values for diabetic states should be fully incorporated into the process of clinical decision making. Less