摘要：

目的: 探讨神经内镜手术、神经导航引导下无框架立体定向穿刺引流术（以下简称穿刺引流术）、小骨窗开颅手术这3种微侵袭手术在高血压脑出血患者术后6个月随访期内卫生经济学差异。方法: 在自发高血压脑出血微创手术治疗（MISICH）数据库中选取16所医疗中心2016年7月至2022年6月行微侵袭手术的651例高血压脑出血患者，包括神经内镜手术219例、穿刺引流术220例、小骨窗开颅手术212例，采用改良Rankin量表（mRS）评估术后6个月神经功能预后，将mRS评分映射为健康效用值，计算质量调整生命年（QALY），构建成本效果分析模型和成本效用分析模型，计算增量成本效果比（ICER）和增量成本效用比（ICUR），采用单因素敏感性分析和概率敏感性分析验证模型分析结果的稳健性。结果: 穿刺引流术以最低平均住院成本（77 351元）和良好的健康效用值（QALY = 0.204年）获得最优成本效用分析（379 110元/QALY），是卫生经济学优势最佳术式。神经内镜手术尽管QALY略高（0.218年），但因耗材与设备成本显著（ICUR约为1 059 630元/QALY），远超国人意愿支付阈值，限制其推广。小骨窗开颅手术QALY最低（0.189年）、成本最高（100 947元），被判定为强支配劣势方案。单因素敏感性分析和概率敏感性分析显示，穿刺引流术的卫生经济学优势最佳，是唯一在不同参数假设和意愿支付阈值下均维持卫生经济学优势的术式。结论: 在当前医疗成本结构与支付能力背景下，穿刺引流术在成本、疗效和卫生经济学优势方面均表现最佳，是高血压脑出血的优选微侵袭术式；神经内镜手术虽具有较高健康效用值，但因成本负担较重，适宜在特定人群中个体化应用；小骨窗开颅手术因成本高、效益低，不推荐作为常规优选方案。本研究为临床手术路径选择与医保支付政策优化提供了系统、量化的决策依据。

关键词: 颅内出血，高血压性, 神经内窥镜检查, 穿刺术, 引流术, 颅骨切开术, 经济学，医学, 费用效益分析

Abstract:

Objective: To evaluate the health economics differences of 3 minimally invasive surgical techniques about neuroendoscopic surgery, frameless stereotactic catheter drainage guided by imaging navigation (puncture drainage), and small bone window craniotomy over a 6-month follow-up period. Methods: Total 651 patients with hypertensive intracerebral hemorrhage treated between July 2016 and June 2022 at 16 medical centers in China were included: neuroendoscopic surgery (n = 219), puncture drainage (n = 220), and small bone window craniotomy (n = 212). Neurological outcomes at 6 months were assessed using the modified Rankin Scale (mRS), which was then mapped to health utility values to calculate quality adjusted life year (QALY). Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) models were constructed to calculate the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR), with one-way and probabilistic sensitivity analyses (PSA) performed to assess result robustness. Results: Puncture drainage achieved the lowest hospitalization cost (77 351 CNY) and favorable health utility (QALY = 0.204 years), resulting in the most favorable CUA (379 110 CNY/QALY), making the optimal surgical approach with the greatest health economics advantage. Although neuroendoscopic surgery yielded slightly higher QALY (0.218 years), its high consumable and equipment costs led to an ICUR of approximately 1 059 630 CNY/QALY, far exceeding China's willingness-to-pay threshold, limiting its broad application. Small bone window craniotomy showed the lowest benefit, with the lowest QALY (0.189 years) and the highest cost (100 947 CNY), and was therefore deemed an economically inferior strategy. One-way and PSA showed that puncture drainage had the greatest health economics advantage and was the only surgical procedure that maintained its economics advantage across different parameter assumptions and willingness-to-pay thresholds. Conclusions: Under the current healthcare cost structure and willingness-to-pay context, puncture drainage demonstrates the best performance in terms of cost, clinical effectiveness and health economics advantage, making it the preferred minimally invasive surgical approach for the treatment of hypertensive intracerebral hemorrhage. Neuroendoscopic surgery, despite higher health utility value, is better suited for individualized use in specific patient populations due to cost constraints. Small bone window craniotomy, with high cost and low benefit, is not recommended as a routine surgery option. This study provides systematic and quantitative evidence to support clinical decision, making regarding surgical pathway selection and the optimization of health insurance reimbursement policies.

Key words: Intracranial hemorrhage, hypertensive, Neuroendoscopy, Punctures, Drainage, Craniotomy, Economics, medical, Cost-benefit analysis

中图分类号: 

• R741