雙能量X光骨密度儀或結合定量超音波儀及雙能量X光骨密度儀在篩檢骨鬆的成本效益

Abstract

研究背景 雖然對於65歲以上婦女或骨折風險等同之小於65歲以下婦女或男性，施以骨質疏鬆篩檢已為骨質疏鬆預防之準則。然而對於在社區實施骨質疏鬆篩檢之實證，特別在成本效益評估上仍有所不足。因此本論文主要有以下研究目標，(1)了解台灣在骨質疏鬆與相關骨質疏鬆所引起骨折之情形;(2) 以QUS為基礎值之個人化骨質疏鬆篩檢發展;(3)進以機率式成本效益分析進行骨質疏鬆篩檢策略評估。 研究方法 我們先建構三階段骨質疏鬆自然病史，利用台灣地區資料估算骨質偏低之發生率及骨質偏低至骨質疏鬆之轉移速率，並以馬可夫決策分析模式建構成本效用分析。我們針對台灣40-80歲成人進行模擬，成本效益分析所使用之參數，主要來自文獻整理，並進一步考量參數不確定性，配適合適之分佈，以進行機率式成本效益評估，折扣率為3%。 結果 骨質偏低之發生率經估算，男性為5.60% (95% CI: 5.38%-5.82%)，女性為5.11% (95% CI: 4.82%-5.42%)，骨質偏低至骨質疏鬆之轉移速率為2%。男性及女性由骨鬆正常至骨質偏低之年風險分別為5.3%及4.9%，骨質偏低至骨質疏鬆之年風險則分別為1.9%及2.3%。每兩年進行DXA篩檢及個人化骨質疏鬆篩檢與不篩檢，其成本效用增量比分別為美金26519.05元及22913.96元。與不篩檢相比，當付費意願為20000元時，個人化骨質疏鬆篩檢有較高之成本效用機率，考量生產力損失時，有類似之結果。 結論 每兩年進行DXA篩檢及個人化骨質疏鬆篩檢圴為具成本效益之預防策略，而又以個人化骨質疏鬆篩檢最具成本效益，此結果提供骨質疏鬆預防之新方向。

Abstract Background Population-based osteoporosis screening has been recommended in women aged 65 years or older or in young women or men who have equal fracture risk. However, the current evidence is still insufficient to study the balance of cost and effectiveness of screening for osteoporosis in community. Objectives In this thesis, we aimed to (1) elucidate the evolution of osteoporosis and osteoporotic fracture in Taiwan population; (2) develop a population-based personalized screening strategy for osteoporosis by using QUS values; and (3) perform the probabilistic cost-effectiveness analysis of the population-based screening strategies under Taiwanese scenario. Methods We applied the three-state Markov model for the progression of osteoporosis in conjunction with the sufficient statistics derived from the empirical data in Taiwan to estimate the incidence rates for osteopenia and the progression rate from osteopenia to osteoporosis. We used the Markov decision tree model to conduct the cost- utility analysis. We collected other parameters from literatures, and further consider their uncertainty by applying appropriate distributions for the probabilistic approach. We modeled the cohort from age 40 years to 80 years. The length of each cycle is 1-year. A 3% discount rate is considered, and applied to both measures of cost and utility. Both payer and societal perspectives are adopted. Results The incidence rates for osteopenia were estimated as 5.60% (95% CI: 5.38%-5.82%) and 5.11% (95% CI: 4.82%-5.42%) for men and women, respectively. The estimated progression rate from osteopenia to osteoporosis were around 2%, yielding annual risk for osteopenia as 5.3% and 4.9% among normal BMD, and 1.9%% and 2.3% risk for osteoporosis among osteopenia men and women, respectively. The incremental cost-utility ratios were USD 26519.05 and USD 22913.96 for biennial DXA and personalized strategy, respectively, compared with no screening. Compared with no screening, personalized strategy has a higher probability of being cost effective with the WTP higher than USD 20,000. The corresponding figures for biennial DXA screening strategy was USD 25,000. After further considering the production loss, we found that the cost for all three policies increased dramatically. However, the incremental cost-utility ratios (ICUR) for both strategies were slower than their counterparts in models without considering production loss.