营养支持对有营养风险患者临床结局的影响和成本效果分析

　　营养筛查、评定和干预是医院营养诊疗的主要组成部分，但是既往的营养筛查、评定和干预研究缺乏营养支持对营养风险患者的成本效果分析。

　　2017年5月，《NUTRITION》正式发表中国医学科学院北京协和医学院北京协和医院、重庆医科大学护理学院、贵州医科大学附属贵州省人民医院、中国医学科学院北京协和医学院阜外医院国家心血管病中心、丹麦哥本哈根大学医院、北京大学中国卫生发展研究中心、约翰霍普金斯大学护理学院、重庆医科大学附属第一医院、北京大学护理学院的研究报告，通过比较营养支持队列与未支持队列进行成本效果分析。

主要发现

  • 营养支持队列患者的感染并发症发生率低于未支持队列。

  • 配对营养支持患者的住院时间显著减少。

  • 增量成本效果分析表明，防止感染并发症所需营养支持成本增量为每例患者392美元。

　　该前瞻观察研究在胃肠外科和消化内科病房筛查有营养风险的患者，并记录未根据营养风险状况就提供营养支持的情况。成本数据来自每个患者的账目报表，有效性按感染并发症发生率计算。为了控制潜在的混杂变量，采用倾向评分匹配，根据匹配人群计算增量成本效果比（ICER）。

  • 倾向得分匹配是一种统计学方法，用于处理观察研究的数据。在观察研究中，由于种种原因，数据偏差和混杂变量较多，倾向评分匹配正是为了减少这些偏差和混杂变量的影响，以便对研究组和对照组进行更合理的比较。这种方法一般常用于医学、公共卫生、经济学等领域。以公共卫生为例，假设研究问题是吸烟对于大众健康的影响，研究者常常得到的数据是观察研究数据，而不是随机对照研究数据，因为吸烟者的行为和结果，以及不吸烟者的行为和结果，是很容易观察到的。但是如果要进行随机对照研究，招收大量受试者，随机分配到吸烟组和不吸烟组，这种研究设计不太容易实现，也并不符合科研伦理，这种情况下观察研究是最合适的研究方法。但是面对最容易获得的观察研究数据，如果不加校正，很容易获得错误的结论，比如拿吸烟组健康状况最好的一些人和不吸烟组健康状况最不好的一些人作对比，得出吸烟对于健康并无负面影响的结论。从统计学角度分析原因，这是因为观察研究并未采用随机分组的方法，无法基于大数定理的作用，在研究组和对照组之间削弱混杂变量的影响，很容易产生系统偏差。倾向评分匹配就是用来解决这个问题，消除组别之间的干扰因素。

  • 药物经济学评价的主要内容是成本（投入）与效果（产出），而成本增量差与效果增量差的比值即增量成本效果比（ICER）。具体到评价治疗方案的ICER，这一比值即为：治疗方案的成本差额÷效果差额。世界卫生组织（WHO）建议ICER低于人均国内生产总值（GDP）1～3倍，根据2016年国民经济和社会发展统计公报，我国人均GDP为人民币53980元（折合7842.51美元）。

　　结果共筛查3791例患者，并入组440例患者进行分析。营养支持队列患者的感染并发症发生率低于未支持队列（9.1%比18.1%，P=0.007）。149对倾向匹配结果相似（9.4%比24.2%，P＜0.001）。在匹配的营养支持患者中，中位住院时间显著减少（13d比15d，P＜0.001）。配对之间的总成本相似（6219美元比6161美元）。增量成本效果分析表明，防止感染并发症所需营养支持的成本增量为每例患者392美元（远远低于WHO建议的ICER）。

　　因此，营养支持与有营养风险患者感染并发症较少和住院时间较短有相关性。增量成本效果比值表明营养支持并未显著增加成本。

Nutrition. 2017 May;37:53-59.

Impact of nutrition support on clinical outcome and cost-effectiveness analysis in patients at nutritional risk: A prospective cohort study with propensity score matching.

Zhang H, Wang Y, Jiang ZM, Kondrup J, Fang H, Andrews M, Nolan MT, Mu SY, Zhang J, Yu K, Lu Q, Kang WM.

Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Nursing School, Chongqing Medical University, Chongqing, China; Guizhou Provincial People's Hospital, Guizhou, China; Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; China Center for Health Development Studies, Peking University, Beijing, China; School of Nursing, Johns Hopkins University, Baltimore, Maryland; First Affiliated Hospital of Chongqing Medical University, Chongqing, China; School of Nursing, Peking University, Beijing, China.

Highlights

  • Patients in the nutrition support cohort had a lower incidence of infectious complications than those in the no-support cohort.

  • Hospital length of stay was significantly reduced among the matched nutrition support patients.

  • The incremental cost-effectiveness analysis suggested that nutrition support costs US $392 per patient and prevented infectious complications.

OBJECTIVES: There is a lack of evidence regarding the economic effects of nutrition support in patients at nutritional risk. The aim of this study was to perform a cost-effectiveness analysis by comparing an adequate nutrition support cohort with a no-support cohort.

METHOD: A prospective observational study was performed in the surgical and medical gastroenterology wards. We identified patients at nutritional risk and the provision of nutrition support by the staff, unaware of the risk status, was recorded. Cost data were obtained from each patient's statement of accounts, and effectiveness was measured by the rate of infectious complication. To control for potential confounding variables, the propensity score method with matching was carried out. The incremental cost-effectiveness ratio was calculated based on the matched population.

RESULTS: We screened 3791 patients, and 440 were recruited for the analysis. Patients in the nutrition support cohort had a lower incidence of infectious complications than those in the no-support cohort (9.1 versus 18.1%; P = 0.007). This result was similar in the 149 propensity matched pairs (9.4 versus 24.2%; P < 0.001). The median hospital length of stay was significantly reduced among the matched nutrition support patients (13 versus 15 d; P < 0.001). The total costs were similar among the matched pairs (US $6219 versus $6161). The incremental cost-effectiveness analysis suggested that nutrition support cost US $392 per patient prevented from having infectious complications.

CONCLUSION: Nutrition support was associated with fewer infectious complications and shorter length of stay in patients at nutritional risk. The incremental cost-effectiveness ratio indicated that nutrition support had not increased costs significantly.

KEYWORDS: Cost-effectiveness analysis; Nutrition support; Nutritional Risk Screening 2002; Propensity score matching

PMID: 28359363

DOI: 10.1016/j.nut.2016.12.004

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