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1、疑难性腹部疾病诊断的费用效果分析 周曾芬1 陈世耀2 王吉耀2 1 昆医附一院消化内科 2 上海医科大学附属中山医院消化内科摘要目的 研究腹腔镜检查在诊断疑难性腹部疾病中的效率（即费用-效果）。方法 将 31例疑难性腹部疾病的诊断方法分四组：基础组，腹腔穿刺腹水检查和 B超检查；增强 CT组，增强CT检查；腹腔镜组，腹腔镜检查；联合组，以上方法联合检查。统计各组的确诊率；以云南省三级甲等医院收费标准，计算各组每确诊 1例所需要的平均费用；与基础组相比后三组每增加 1例确诊所需要增加的费用；并作敏感性分析。结果 基础组、增强CT组、腹腔镜组和联合组的确诊率分别为 2/31、 6/31、 30/3
2、1和 30/31；每确诊 1例平均费用分别为3348.90元、4511.43元、1455.49元、2124.14元；与基础组相比，每增加 1例确诊，后三组所需要增加的费用分别为5092.70元、1320.25元、2036.65元。可见，腹腔镜组和联合组明显优于增强CT组，而且以腹腔镜组为最优。敏感性分析仍然支持本研究结果。结论 疑难性腹部疾病进行腹腔镜检查可尽早明确诊断、及时治疗，其成本费用最少。关键词: 腹腔镜检查 腹腔穿刺检查 影像学检查 疑难病 费用-效果分析中国图书分类号: 573.2A cost-effectiveness study of diagnosis by laparasc
3、opy of difficult and complicated abdominal diseases Zhou zengfen Lu shuan Qin xinglu Cui rong Department of Gastroenterolong，the First Affilia Hospital of Kunming Medical College，Kunming，650032Chen shiyao Wang jiyao Department of Gastroenterolong，zhongshan Hospital，Shanghai Medical University，Shangh
4、ai 200032Abstract Aim To assess the cost-effectiveness of diagnosis by laparascopy of difficult and complicated abdominal diseases . Methods The diagnostic methods ofthe 31 cases of difficult and complicated abdominal diseases were divided into four groups: a basic group（namely, repeated ascites tes
5、ts after puncture and ultrasonography），a enhanced CT group， a laparatory group and a alliance group of the above mentioned three groups The diagnostic rates, the average costs per one case which was correctly diagnosed in the above four groups, and having compared with the based group , the increase
6、d costs in the latter three groups while added one case was diagnosed correctly were calculated respectively. The costs were calculated according to the standard of A grade hospitals in the province of Yunnan. Sensitivity analysis of the four groups was made, too. Results The diagnostic rates were 2
7、/31, 6/31, 30/31 and 30/31; the average costs were￥3348.90, ￥4511.43, ￥1455.49, and ￥2124.12 in the four groups respectively; having compared with the basic group, the increased costs were￥5092.72, ￥1320.25 and￥2036.65 in the latter three groups respectively while added one case was correctly diagno
8、sed. So, the efficiency in the laparatory group and the alliance group was more excellent than in the basic group and the enhanced CT group and the efficiency in the laparatory group was the most excellent among the four groups. The sensitivity analysis of these materials was accordant with this res
9、ult, too. Conclusion the difficult and complicated abdominal diseases should be diagnosed by laparascopy as early as possible directly so as to obtain their correct diagnoses and treatments. And the cost of the laparascopy group was the least among the four groups.Key words Cost-effectiveness analys
10、is Difficult and complicated abdominal diseases Laparascopy Ascites tests after puncture Enhenced CT scanning 腹痛、腹水和腹块是临床常见征象，结合病史，体征和常规化验检查，大部分病人可获明确诊断，但仍有约1/3的病例难以诊断。对疑难性腹部疾病，目前主要依靠常规生化、腹水实验室、胃肠镜等检查，然而,甚至在进行了CT、MRI等影象学检查之后仍不能明确诊断。因此不明原因的腹痛、腹水、腹块的病因诊断一直是临床的一大难题1。腹腔镜检查由于技术的更新，能直接窥视到大部分壁、脏层腹膜，肝、胆、脾、胃
11、肠、肠系膜、大网膜和盆腔，对病变典型部位直视下取材活检准确性高，文献报道其确准率均在90%以上1-2 ，对疑难性腹部疾病有独特的诊断作用。我们的临床研究中也显示腹腔镜优于影象学检查3。由于腹腔镜检查需要住院进行，对病人具有一定的创伤性和潜在的并发症，因而可能增加病人的费用。本研究从经济学角度，采用费用-效果分析评价腹腔镜检查与影象学增强CT分别或联合检查在诊断疑难性腹部疾病中的优劣。1 研究对象和方法 1 1分析模型：腹部疑难疾病按临床表现分为以腹痛、腹块和腹水表现三种。本研究中疑难病例指经常规病史询问、详细体格检查、实验室检查和相应的胃肠钡餐检查、胃镜肠镜和ERCP检查仍不能确诊者。分析模型
12、见图1所示。研究病例均接受全部检查，按分析模型比较增强CT检查和腹腔镜检查以及二者联合应用在诊断疑难腹部疾病中的费用-效果。图1. 疑难腹部疾病的费用-效果分析模型 腹部疾病 常规检查 明确诊断 疑难病例 进入研究入选病例重复腹水检查增强CT检查 腹腔镜检查(基础组) (增强CT组) (腹腔镜组) 确诊 未确诊确诊 未确诊确诊 未确诊1 2费用的计算：本研究采用患者应付的费用作为粗的费用资料。收费标准以云南省卫生厅对三级甲等医院的核价标准为依据。总的费用包括三部分：(1)直接医疗费用，主要包括基本检查费用(血尿粪常规检查，肝肾功能，腹水检查，钡餐和胃肠镜检查， AFP，CEA，CA199等肿瘤
13、抗原检查，心电图，胸片以及B超检查等)。特殊检查费用(CT扫描，造影剂，造影剂过敏抢救费用，腹腔镜检查手术费用，住院费用，预防用药费用，并发症处理费用等)，费用按1995年云南省三级甲等医院检查和药物收费标准计算，如表1所示。(2)直接非医疗费用，主要包括患者及家属就诊交通费用，患者特殊饮食费用等。(3)间接费用，主要包括病人就诊或住院误工费用，家属陪伴误工费用等。费用计算根据误工的天数乘以每天的平均收入计算。表 1. 云南省1995年三级甲等医院部分检查和药物收费标准 项 目 费用(人民币元)1门诊挂号费 0.502住院床位费(包括护理费用)2.673检查： 血常规15.00 凝血酶原时间1
14、1.50 肝功能48.80 肾功能6.40 电解质11.40 定血型2.00 心电图4.50 腹水穿刺术5.00 腹水常规1.50 腹水生化5.10 腹水细菌培养5.00 腹水浓缩找抗酸杆菌2.00 腹水浓缩找肿瘤细胞10.00 腹部B超检查(腹部盆腔)30.00 CT扫描(腹部盆腔)350.00 腹腔镜手术500.00 腹腔镜手术麻醉(局麻)46.00 病理组织学检查30.00 胃管4.44 倒尿管4.224药物： 杜冷丁2.00 阿托品0.40 非那根0.40 安定0.35 泛影葡胺造影剂(20ml/支)16.90 头孢塞肟钠(/g)26.50 羟氨苄青酶素(/g)9.25 氧哌嗪青酶素(/g)7.001 3 效果的估计：采用我们所进行的临床研究结果资料，包括重复腹水检查和B超检查的结果；增强CT检查的结果；腹腔镜检查的结果以及联合增强CT和腹腔镜检查的结果。1 4费用-效果分析：基础组定义为单纯重复腹
