PHAN TICH CHI PHI - HIEU QUA COA CAC CAN THIEP DI^U TRj BENH TAM THAN PHAN LIET TAI VIET NAM
Nguygn Thu Hi, Nguyen QuJTih Anh, Bdi Ngpc Linh, Nguyin Thanh Huomg Tru&ng Dpi hpc Yti Cdng cpng, Hd n$i
D$l vin a i . Nhim cung cip bing chO-ng tin cfiy v l tfnh chi phl-hi$u qui cCia cic can thi$p diiu trj b$nh tim thin phfln iiOt (TTPL), nghiSn cCru dug-c thyc hl$n v6i mye tISu: Xfic dinh g6i can thi§p dilu trj TTPL cd chi phl-hl$u qui cao nhit. c6 cSn nhic flln ib mgnh oda bing chirng, tinh cdng bing, tinh khi thi, tinh chSp nhSn va tfnh bin v&ng. Phuong phip. MO hinh Markov dupe xSy di/ng d i tinh tofin chi phi vfi hi$u quS cua cfic can thiep thuOc hai nhiim Ifi llOu phip h6a 6<jgc vi nhin thi>c gia dinh. Cfic tham &b diu vfio che mfl hinh di/cc liy tCr s4 li$u tai ViOt Nam vfi ting quan tfii liiu trfin thi gidi. Kit qufi. So sinh vdi phirong fin "khflng can thiip", tit c i can thi$p aiu cfl tfnh chi phl-hi^u qui cao. Chi phr-hi$u qufi nhit Ifi sCr dyng thuic an thin kinh (ATK) thi h$ cQ kit hpp vb\ li$u phip nhin thif c gia dlnh (tiit ki$m 6.545.718 ding cho 1 nflm sing hiOu chlnh theo mdc dO tin tit ngfin ngira di/pc tfing thfim). Kit lufin. G6i can thifip tir i/u b-ong diiu tri bfinh TTPL t^i c^ng ding b Vifit Nam hifin nay nin bit diu bing sir dyng ATK thi hfi cQ kit h^'p v6l lifiu phfip nhfin thi>c gia dinh.
TO kh6a: Phin tfch chi phf-hlfiu qufi, tfim thin phfin iifit, lifiu phfip h6a dii^c, li§u phip nhfin thirc gia dlnh
I. DAT VAN DE
T^i Vi?t Nam, cic b?nh tam than kinh la nguy6n nhin hing dau cua ginh nang b$nh tat nim 2008, ttong d6 TTPL ehiem 7% (xep tini 5) tong ginh nang b?nh tgt eua nhom b?nh niy [1]. "Dv in bao v? siic khoe tam tiian (SKTT) cpng dong" ttong khu6n kh6 ciia Chuong trinh mye tieu qu6c gia phdng chdng mpt so b?nh xa hpi giai doan 2006-2010 dupe Thu tu6ng chlnh phu phS duy^t ngiy 17/7/2007 tiie hipn cam ket vi no l\rc cua Vipt Nam ttong chim s6c, dieu h^, hu6ng tiM giira ginh n$ng bpnh tit do TTPL gay ra. Trong boi cinh h^n ch^ v^ nguon
kinh phi, cic nghien cuu dinh gii ehi phi-hi^u qui cua cic can thipp dieu trj TTPL nhim eung c^p bing chcmg ding tm c^y de ho ttp cho cac nha ho^ch djnh chinh sich ttong vipc uu tien phin b6 ngu^n lyc la hfit sue cin thifit T^ Vipt Nam, chua c6 mpt nghifin cijru nao dupe thvc hipn ttong khi da c6 nhieu phan tich chi phi- hipu qui ve chu de nay da dupe thyc hipn ta:
nhieu nude tten the gidi. Tir nhung ly do tten, nghien cuu dupe thyc hipn vdri mye tieu: Xdc djnh goi can thifp diiu trj TTPL cd chi phi- hifu qud cao nhat. co cdn nhdc den dp mgnh cua bang chung. tinh cong bang, tinh khd thi, tinh chap nhpn vd tinh ben vimg.
Tic gii: Nguyin Thu Hi
Dja ehi: Trudng D?i hpc Y t^ edng cpng 138 Giing Vd, H i Npi
Dipn tiio?i: 0988976687 Email: [email protected] Ngiy nhin bii: 16/1/2012 Ngay dang b i i : 20/4/2012
Phin bipn 1 : PGS.TS. Ph^un Tri Dung Trudng DH Y te Cdng cpng.
Phin bipn 2 : TS. Vu Xuin Phii Bpnh vi^n Phoi trung uong.
54 Tap chi Y hpc du ph6ng. Tap XXU, s^ 2 (128)
Bing 1. Cic phiFcng i n can thl$p dirpn: phfin tfch
Phuwng i n 1. "KhSng can thl§p"
2.ATKthih#cu
3. Risperidone 4. Clozapine 5. Olanzapine
6. ATK t h i h§ cu (67%)+Rispendone (33%)
7. ATK thl h§ cu+Lipu phip nh§n thi>c gia dinh
8. ATK thl h$ cu (67%)+RisperidonB (33%)+Li$u phSp nh§n thi>c gia dlnh
G i i djnh Khflng triin khai Dy i n bio v§ SKTT cOng ding 100% ngirbi binh SCP dyng ATK thi h§ cQ (ChlopnDmazine, Haloperldol, Levomepromazlne)
100% ngudi bfinh si> dMng Risperidone 100% ngufl'i binh si> dgng Clozapine 100% ngufl'i b$nh sQ-dung Olanzapine
67% ngufl'i bfinh sir dgng ATK thi hfi cO vfi 33% si> dyng Risperidone
100% nguiri b^nh si> dgng ATK t h l hfi cfl kit hp'p lifiu phfip nhfin thCrc gia dlnh
67% ngufl'i bfinh sO dgng ATK t h l h$ cQ v i 33% si> dgng Risperidone kit hpp lifiu phfip nhfin thirc gia dlnh
IL PHl/OfNG PHAP NGHIEN CtTU Tien hanh nghifin clhi theo 3 budc.
Bu&c 1-Lua chpn cdc can thi^p dua vdo phan tich: li cic can thipp dya trfin cdng d6ng, lya chpn dya tren eae tieu chi:(l) khi thi dfi thuc hien d Vipt Nam; (2) nhan dupe sy uu tien/quan tam eua Du dn bdo vf SKTT cpng ddng hay eic bic si dieu tri; (3) co bang ehung ve hipu qua cua can t h i ^ ; (4) eo thdng tin vfi chi phi cua can thifip. Tii do, 8 phuong an can thipp dupe dua vao phin tich (Bing 1).
Bu&c 2-Xdy dung mo hinh vd tinh todn Do lu&ng hi$u qud: Md hinh Markov dupe xay dyng eho hai gidi dp tuoi tii 15 den 100 de tinh toin ehi phi cung nhu hipu qui cua cic phuang in can thi^p khic nhau vdi quan tiie dich l i toan bp ngudi b$nh TTPL eua Vi§t Nam nam 2006 [2]. Mdi nam ttong md hinh, ra0t ngudi bpnh ed Ihfi d 1 ttong 3 tinh tr^g:
dang mic bpnh, khdi b$nh ho^c tu' vong (Hinh 1). Xic suat (probabilities) thay doi gi&a 3 tinh
ttgng ttfin dupe tinh dya ttfin cic sd Upu ttong nudc vi qu6c t^. S6 lipu hipn mac TTPL nam 2006, ty Ip khdi bpnh va ty Ip chet/mac theo tu6i, gidi cia ngudi bpnh TTPL dupe l4y tii nghien cuu "Ganh nang bfinh tat d 'S^pt Nam nim 2008" [1]. Hipu qua cua eic phuong in so vdi "khdng can thipp" dugc do ludng bang sy chenh l^ch giiJa so nam song khde manh hi^u chinh theo miic dp tan tat (DALYs-Disability Adjusted Life Years) ciia. quan the ngudi bpnh ttong md hinh khi su dyng phuong in dd so vdi khi "khong can thi^p" (cd nghia li sd DALYs ngin ngiia dupe nhd su dyng phuong in d6).
Do lu&ng chi phi: Cic nguyfin tic, gii djnh khi do ludng chi phi bao g6m: (1) Do ludng hi gde dp Chinh phii; (2) chi phf phit sinh lifin tyc tii luc ngudi b§nh b^t dau dupe dua vio nghien euu den khi "tii vong" ho|c
"khde m ^ " ; (3) tiiu thip s6 li$u v^ chi phi ttong nim 2009, va sii dyng chi s6 gii tifiu ddng (CPI-Consumer Price Index) d^ di^u Tgip chi Y hpc du phdng, Tgp XXU, s6 2 (128) 55
chinh ve nim 2006 eho phii hprp vdi q u ^ th^
dich (toin bd ngudi b§nh nim 2006); (4) sii dyng ty l§ chilt kh^u 3% d^i vdi ci chi phi vi hipu qui. Cic ehi phi dupe tinh toin g6ra;
(1) chi phi cho hogt d^ng phit hi§n, theo ddi, cdp phit thu6c vi quin 1^ ngudi b§nh tgi cdng d6ng; (2) chi phi tiiu6c ATK; (3) ehi phi di^u tii/dy phdng tic dyng phy; (4) ehi phi dilu trj ndi mi t&i CO sd y t l ; (5) chi phi tiiyc hi§n li§u phip nh$n thiic gia dlnh. Cic s6 li$u dupe thu Ui&p td Dy in bio v§ SKTT cOng ddng, b§nh vi§n tam tiiJin TWl vi m0t s6 gii djnh cho tinh toin dupe thu th^p tii tong quan tii li§u [3-5].
Tinh todn ty so chi phi-hi^u qud tdng them (ICER, Incremental Cost-Effectiveness Ratio) vd phdn tich tinh khong chdc chdn:
ICER dupe tinh theo cdng thiic:
Chi phi--Chi phi, ICER= ^^—^ ^-^—
Ket qui J-Ket qui J
(Vai chiphi/ket qud I la eua phuang dn doi chimg vd ehi phi/ket qud 2 la eua phuang dn duffc de cgp din). ICER cho bilt dl thu thfim dupe 1 don vj kit qui thi cliu thfim hay tilt kipm bao nhifiu don vi ehi phi. VI ky thuit md hinh hda dua ra eic ket qui ttong dieu kipn cd tinh khdng chic chin (do cic tham so dau vio vi do md hinh) nen ky thugt md phdng Monte Carlo thdng qua ph4n mem tich hpp Ersatz ttong excel dupe dung de phin tich tinh khdng chin chin. Cic kit qui dupe trinh biy dudi dgng ty s6 hi§u qui chenh Ipch ICER vi
khoing tin ciy 95% [2].
e
NgudiTy !(• kiwi
KIK'IC m^inh
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Tvl?_
chet/mac vd ly .sudt
Ur vong TCr vong vi lu sal, b^nh tai lien quan den lang
can va nguyen nhan khac
Hinh 1. MO hinh tinh tr^ng sOc khde (Md hinh Markov)
Bu&c 3 - Ddnh gid cdc tieu chuin l\ftt chpn liin quan din chlnh sdch: Nhim dua ra kit l u ^ vi khuyen nghi phu hpp vdi b6i cinh Vi§t Nam, nhdm nghien eiiu tifin hinh 4 cudc phdng v ^ siu vi 2 cudc thio l u ^ nhdm vdi 14 chuySn gia lim vipc ttong lmh vye SKTT ve dd mgnh ciia bing ehiing, tinh cdng bing, tinh khi thi, tinh chip nhin vi tinh ben vung cua cic phuong in can thipp [2].
IIL KET QUA
3.1. Hifu qui cua cic phinrag i n can thifp Nhin chung, hifu qui ciia thu6c ATK thl hp mdi khdng vupt ttpi nhilu so vdi thudc ATK the h? cQ trong vipc giam miic dp trim trpng ciia bfnh (Bing 2).
56 Tap chi Y hoc di; phdng, T^p XXH, s6 2 (128)
Bing 2. Hi$u q u i cOa ric phinmg i n can thi$p TTPL so vd<l "khdng can thl$p"
d>Vi$t Nam nim 2006
Phvcmg i n can thl$p Sl DALYs ngin ngira 6wyc N {95%CI)
ATK t h l h9 cfl Risperidone Olanzapine Clozapine
498.061(448.491:560.145) 558.194(494.525;632.237) 631.649(498.614:658.341) 586.273(531.854;707.205) ATK t h l h$ cO + I1$u ph6p nhin thdc gia dinh 703.641 {703.418:965.903) Vifc ket hpp lifu phip nhgn thiie gia cii kit hpp vdi lipu phap nhgn thuc gia dinh dmh vdi thucic ATK mang lgi hifu qui cao giup ngan ngira dupe khoing 700.000 nam ttong vipc giim mde dd trlim ttpng ciia bfnh. s6ng khde mgnh mat di do tin tgt (700.000 Cy till, phuong in sd dyng tiiu6c ATK till hf DALYs) so vdi khi "khdng can tiiifp".
Bing 3. Chi phi cOa c i c can thIfp (tinh t o i n cho timg ngu'fl'i b^nh trong 1 nim) Phu'O'ng i n can thi$p
ATK thl h§ cO Risperidone Olanzapine Clozapine
Chf phf (ddng/nim) 1.918.789 2.018.372 2.402.633 2.718 997 ATK t h l h$ cQ + li#u phSp nhin thi>c gia dinh 1.888.645
3.2. Chi phf cua cic phuong i n can thifp Kit qui udc tinh chi phi cho tung phuong in dupe lift ke tgi Bang 3. Cac thude ATK thl hf cu ludn chiera uu the ve ehi phi vi ttong cic tiiu6c ATK thl hf mdi, phuong in sd dung Risperidone cd chi phi thap nhat.
3 J . Kit qui so sinh chi pbi-bif u qui Khi so sinh vdi phuong in "khdng can thifp", tit ci cic can thifp diu cd chi phi thip hon vi hifu qui cao hon (Bdng 4). Trong dd, ehi phi-hifu qui nh^t l i phucmg in "ATK thl hf eu + lifu phip nhin thdc gia dlnh", tilp din
li "ATK the hf cu" vi "ATfC till hf cii (67%) + Risperidone (33%)". Xet Hfu phip hda dupe don thuin, phuong in cd chi phi-hifu qui eao nhat la su dyng ATK the he cu (ICER so vdi
"khdng can thifp" ^6.470.804 ddng/lDALY ngin ngda dupe ting thfim, cd nghia la su dung ATK thl hf cu thi se tilt kifm dupe gan 6,5 trifu dong cho 1 DALY ngin ngiia dupe ting them), tiep den la phuoog in thay the ATK Ihl hf cii bang Risperidone eho 1/3 sd ngudi bfnh (ICER so vdi "khdng can thifp" =-5.792.695 ddng/lDALY ngan ngua dupe ting thfim).
Tap chi Y hpc diiphong. Tip XXH, so 2 (128) 57
Bing 4. T^ s6 ICER cilia cic phuvng i n can thf^p khi so sinh v&\ "khdng can thf^p"
Phirvng i n can thifp Tf 86 ICER (95%CI)
ATK thl h i cQ Risperidone Olanzapine Clozapine
ATK thl he cG (67%) + Risparidone (33%) ATK thl h i CO + Lilu phip nhin thdc gia dlnh
ATK thl h$ cfl (67%)+Rlsperidone {33%)+Lliu ph6p nhin thdc gia dlnh
-6.470.804 (-7.186.005;-5.753.613) -5.213.498 (-5.884,922.-4.603.591) -2.698.846 (-3.421.165.-2.595.205) -1.206.766 (-1.332.569.-997,565) -5.792.695 (-6,691.297,-5.332.117) -6,545.718 (-6.547.795;-4.768.425) -2,963.878 (-3.194.625,-2.257.077)
Tuy nhifin, khi xfit den gdi can thifp kit hpp thi ket qui chi rd can thifp cd chi phi-hifu qui cao nhat li phuong in "ATK the hf cQ+lifu phip n h ^ tiiuc gia dhih" (ICER = -6.545.718 dong/l DALY ngin ngua dupe ting thfim). Cy the hon, khi kit hpp su dyng thuoc ATK the hf cu vdi lifu phip nhin thdc gia dhih thl bin than lifu phip nhgn thdc gia £nh da mang l^i kfit qui tiet kifm chi phi li 1.893.242 dong eho moi DALY ngin ngiia dupe ting thfim. Tiep din li phuong in su dyng ATK the hf cii cho 2/3 ngudi bpnh vi Risperidone cho 1/3 ngudi bfnh kit hpp vdi lifu phip nhgn thdc gia dlnh aCER = -2.963.878 d6ng/l DALY ngin ngda dupe ting them).
Kit qui phdng van siu vi thio luin nhdm chuyen gia SKTT ve df mgnh eda bing chdng, tinh cdng bing, tinh kha thi, tinh chip nhgn vi tinh ben vung cung cho thay sy tuong dong ve thu ty sip xep cic can thifp theo tinh chi phi-hifu qui dupe nit ra td ket qui tinh toin theo md hinh nhu dupe trinh biy d tten.
IV. BAN LUAN
Day Ii nghifin cuu diu tifin vl ehi phi
- hifu qui cda eic can thifp dilu tn TTPL sd dyng ky thugt md hinh hda t^i Vift Nam.
Tren till gidi da cd cic nghifin cuu sd dyng ky thuit tuong ty nhung At it de cgp din can thifp khdng sd dyng thu6c ATK (vi dy nhu lifu phip nhan thdc gia dinh) nhu nghifin edu niy.
Nghifin cuu ed mpt so uu difim: (1) chi phi eiia can thifp dupe tinh toin dya tren cic nguon so hfu ding tin cgy; (2) hifu qui cua can thifp dugc do ludng qua so DALYs ngin ngda dupe;
(3) ed xfit den tinh khdng chic chin cua so lifu;
(4) ky thugt md hinh hda dupe thyc hifn md phdng theo mdt nghifin cdu tgi Thii Lan, do viy kit qui nghien ciiu ed tinh so sinh.
Nghien ciiu vSn cdn mft s6 hgn chi: (1) phii su dyng mpt s6 gii djnh td cic nghien cuu tSng quan dupe thyc hifn t ^ cic nude phuong Tfiy do hgn ehl ve s6 lifu ttong nudc vi cic nude ttong khu vye; (2) md hinh hda chi phi vi hifu qui ttfin cic trudng hpp mic trung binh ed thl khdng hoin toin chhih xic nhung do hgn chi vl s6 Ufu nen hifn t^i day li ky thu§t tot nh4t cd the thyc hifn [6], do dd trong tuong lai, khi ed cic s6 lifu lam sing vi dich tk hpe cda tdng c i nhin, han chfi niy c6 thl dupe khic phyc bing kp thugt mo phong vi m6; (3) chi phi 58 T^p chi Y h(?c d^ phdng, T&p XXH, s6 2 (128)
dieu tri npi trd chua dupe tinh day dd do ddng gia dinh lay tu mpt nghifin cdu vl phi dich vy bfnh vifn [5], cin thilt phii cd eic nghifin cdu ve chi phi dilu tri bfnh tam than de khic phyc ban che nay.
V. KET LUAN
Ket qui phin tich td md hinh cho tiiky, khi so sinh vdi "khdng can thifp", 3 phuang an can thifp c6 tinh chi phi - hifu qui cao nh^t la "ATK thl hf cii + lifu phip nh|n thdc gia dhih", "ATK till hf cu", "ATK thl hf cfl (67%) + Risperidone (33%)" (theo thd ty giim dAn v^ tinh chi phi-hifu qui). Cin nhae vdi kit qui dinh gii vl dp manh cda bing chiing, tinh edng bang, khi thi, chap nhan vi ben vung, nhdm nghifin cuu ket luan rang thu ty sap xep cua cae phucmg in khi xet den tinh chi phi-hifu qui khdng thay doi vi gdi can thifp t6i im ve ehi phi-hifu qui nfin bit diu bing sd dyng ATK thfi hf cii kit hop vdi hfu phip nhgn thdc gia dmh.
Mic dd cdn ton tai mpt so h ^ che, diy vhi li mft ttong nhung phan tfch chi phi-hifu qui cua cac can thifp dieu tn TTPL tgi cpng dSng dau tien dupe thyc hifn tuong doi bai b§n tai Vlft Nam. Canjilp tuc cd nhung d^nh gii kinh tfi y te tilp theo de cung cap tiifim bang ehung cho hoach dinh chinh sach Uen quan dfin TTPL ndi rieng va cic vin de SKTT noi chimg trong Dy in bio vf SKTT cpng dong. D6ng
tiidi, vifc cii thifn tinh sSn cd cda cic ngu6n thdng tin thd d p phyc vy cho dinh gii kinh te y tl v^ cic van de SKTT cung cin dupe chd ttpng.
TAI LIEU THAM KHAO
1. NhungN.T.,LongH.K.,LmhB.N.,VosT, Anh N. D. Huong N. T, Ginh ning bfnh tilt vi chin tiiuong d Vift Nam 2008. 2011, Hk Nfi: Nxb Yhpc.
2. Drummond, M.F., et al.. Methods for the economic evaluation of health care programmes. 3rd ed. 2005, New York:
Oxford University Press.
3. Phanthiman, P., Schizophrenia m Thailand:
Enabling better information for efficient solutions, m The School of Population.
2010, The University of Queensland Queensland, p. 168.
4. Leueht, S., et al., New generation antipsychotics versus low-potency conventional antipsychotics: a systematic review and meta-analysis. Lancet, 2003.
361(9369): p. 1581-9.
5. Xuyen, N.T., et al.. Phi dich vy Bfnh vifn:
Phuong thdc thanh toin ttpn gdi tiieo tiirdng hpp bfnh. 2007, Ha Npi: Nhi xb Y hpc.
6. Heeg, B.M.S., et al., Modelling approaches: the ease of schizophrenia.
Pharmacoeconomics, 2008. 26(8): p. 633-48.
Tap chi Y hpc du phong, Tgp XXn, so 2 (128) 59
COST - EFFECTIVENESS ANALYSIS OF INTERVENTIONS FOR SCHIZOPHRENIA IN VIETNAM
Nguyen Thu Ha, Nguyen Quynh Anh, Bui Ngoc Linh, Nguyen Thanh Huong Hanoi School of Public Health
Inttoduetion. To provide reliable evidences on cost-effectiveness of interventions for schizophreiua in Vietnam, this study aims to determine the optimal package of schizophrenia different interventions, taking into account second stage filter criteria (strength of evidence, equity, feasibility of unpleraentation, acceptability to stakeholders, and sustainability). Methods. Markov model is developed to estimate cost and effectiveness of drug interventions and family intervention.
Input parameters are estimated by using Vietnamese data and international research.
Results. When compared with 'do nothing'
scenario, all interventions were considered to be very cost-effective. The most cost- effective one is a combination of typical antipsychotics and family mtervention (ICER=-6.545.718VND/1DALY averted).
Conclusion. When it comes to second stage filter criteria, the results indicated that the most cost-effective intervention package in Vietnam should stari with using typical antipsychotics combined with family intervention.
Keywords: Cost-effectiveness analysis, schizophrenia, drug interventions, family intervention
60 T^p chi Y hpc dv phdng, TSp XXH, s6 2 (128)