第五章 討論
5.6 結論
本研究的結論為：對於胃癌風險較高的馬祖地區民眾，相較不進行任何介 入，幽門螺旋桿菌糞便抗原檢查和碳 13 尿素呼氣試驗的胃癌初段預防策略皆符 合成本效果。幽門螺旋桿菌糞便抗原檢查與碳 13 尿素呼氣試驗的相對成本效 果，可能會受到糞便抗原檢查的敏感度的影響。在支付意願金額較高時，尿素呼 氣試驗有較高的可能性符合成本效益，反之，在支付意願金額較低時，糞便抗原 檢查有更高的可能性符合成本效益。因此各個國家或地區在擬定大規模的幽門螺 旋桿菌根除計畫以預防胃癌時，應該要考量一些重要參數的影響並訂定合適的支 付意願以進行決策。
表 3-1. 流行病學參數基準值以及敏感度分析範圍
Variable Baseline value Distribution for probabilistic
Reference
Prevalence of H. pylori infection, %
62.1 (40-70) β(1651, 1007) (Bair et al., 2020;
Lee et al., 2006) GC incidence of
population without H.
pylori infection, %
HPA GC incidence of
population with H.
pylori infection, %
HPA &
(Helicobacter &
Cancer
表 3-1. 流行病學參數基準值以及敏感度分析範圍 (續完) Variable Baseline value Distribution for
probabilistic
Reference
GC incidence of population with H.
pylori treatment, %
HPA & (Lee et al.,
6 (Helicobacter &
Cancer
Transition probability of GC to death, %
20.33 HPA
Prevention strategy characteristics, %
Attendance rate 71.8 β(2658, 1042) (Lee et al., 2006) SAT sensitivity 88 (80-100) β(50, 7) (Lee et al., 2014) SAT specificity 100 (68-100) (Lee et al., 2014) UBT sensitivity 97.8 β(361, 8) (Chen et al., 2003) UBT specificity 96.8 β(179, 6) (Chen et al., 2003) H. pylori eradication
with standard triple therapy, %
86.9 (60-95) β(770, 166) (Lee et al., 2006;
Wang et al., 2014)
Abbreviations: RR, relative risk; GC, gastric cancer; HPA, Health Promotion Administration; SAT, stool antigen test; UBT, urea breath test.
Data in parentheses are the range used in sensitivity analysis.
specified.
表 3-2. 競爭死因死亡率
表 3-3. 成本參數基準值以及敏感度分析範圍
Variable Baseline value Distribution for probabilistic
Reference
Direct costs, U.S. $ Initial management of advanced gastric cancer
9,750 Triangle (975, 9750, 52000)
NTUH &
(Parsonnet et al., 1996)
Continuing treatment for advanced gastric cancer
294 NTUH
Terminal cancer care 8,938 Triangle (894, 8938, 52,000)
NTUH &
(Parsonnet et al., 1996)
C13 urea breath test 36.3 Triangle (10, 36.3, 140)
NHIA & (Makris et al., 2003) H. pylori Stool
antigen test
8.22 NHIA
(Parsonnet et al., 1996)
Indirect costs
Outpatient Time per visit, h
4 NTUH
Outpatient visit per year
4.68 NHIA
Person accompanied for confirmation or outpatient
hospitalization, d
21 NHIA
Inpatient recovery at home, d
20 NTUH
Person accompanied for inpatient care
1.25 NTUH
表 3-3. 成本參數基準值以及敏感度分析範圍 (續完) Variable Baseline value Distribution for
probabilistic
Reference
Average GDP per person, U.S. $
25,792 DGBAS
Average monthly work, h
169.4 DGBAS
Production value per hour, U.S. $
12.7 DGBAS
Discount rate(%) 3
Abbreviations: NTUH, National Taiwan University Hospital; NHIA, National Health Insurance
Administration; GDP, gross domestic product; DGBAS, Directorate General of Budget, Accounting and Statistics, Executive Yuan.
Triang (a,b,c) = triangular distribution with minimum a, mode b, maximum c. The base-case values were applied unless otherwise specified.
表 3-4. 根除幽門螺旋桿菌對於預防胃癌的效益：隨機對照試驗
Study Location Design No. of subjects Risk Ratio 95% CI Follow-up (years) Fukase et al. 2008 Japan RCT* 544 0.353 0.161-0.775 3
Choi et al. 2018 Korea RCT 396 0.50 0.26-0.94 5.9 Li et al. 2019 China RCT 3365 0.48 0.32-0.71 22
*RCT = randomized controlled trial.
表 3-5. 根除幽門螺旋桿菌對於預防胃癌的效益：統合分析
Study Design Content Odds ratio 95% CI Lee et al. 2016 Meta-analysis 24 studies 0.54 0.44-0.64 Ford et al. 2020 Meta-analysis 7 RCTs* (healthy
individuals)
3 RCTs (patients with gastric neoplasia)
0.54
0.49
0.40-0.72
0.34-0.70
*RCTs = randomized controlled trials.
表 4-1. 胃癌預防策略的累積效果 Age (y) Cumulative
effectiveness of no intervention (y)
Cumulative
effectiveness of UBT screening (y)
Cumulative effectiveness of SAT screening (y)
40 1 1 1
表 4-1. 胃癌預防策略的累積效果 (續完) Age (y) Cumulative
effectiveness of no intervention (y)
Cumulative
effectiveness of UBT screening (y)
Cumulative effectiveness of SAT screening (y) 73 20.53806 20.59007 20.58823
74 20.81749 20.87263 20.87064 75 21.08197 21.14025 21.13812 76 21.33166 21.39307 21.39079 77 21.56662 21.6313 21.62886 78 21.78707 21.85507 21.85247 79 21.99322 22.06456 22.0618 80 22.1853 22.25995 22.25703 81 22.36356 22.44146 22.43838 82 22.5282 22.60938 22.60615 83 22.67953 22.76397 22.76058 84 22.81788 22.90551 22.90196
表 4-2. 胃癌預防策略的累積成本 Age (y) Cumulative cost of
no intervention (US $)
Cumulative cost of UBT screening (US $)
Cumulative cost of SAT screening
表 4-2. 胃癌預防策略的累積成本 (續完) Age (y) Cumulative cost of
no intervention (US $)
Cumulative cost of UBT screening (US $)
Cumulative cost of SAT screening (US $)
73 399.7775 362.0073 317.8492 74 418.1841 374.1993 330.6839 75 435.8911 385.9352 343.0373 76 457.0874 399.9959 357.8359 77 477.905 413.8172 372.3807 78 498.0654 427.2136 386.4766 79 517.3637 440.0484 399.9798 80 535.6524 452.2225 412.7863 81 556.2865 465.9742 427.2497 82 576.0481 479.1598 441.1154 83 594.6947 491.6161 454.2119 84 612.0619 503.2317 466.4223
表 4-3. 增量成本效果比基準值分析
Outcome No intervention UBT screening SAT screening Cost, US $ 612.062 503.232 466.422 Effectiveness, y 22.818 22.906 22.902 Comparison using
ICER values No intervention as reference
━ Cost saving Cost saving
SAT screening as reference
━ 10,366.825 ━
表 4-4. 單向敏感度分析
Variables ICER (UBT screening vs SAT screening)
Prevalence of H. pylori infection, %
40 18,969
47.5 15,154
55 12,379
62.5 10,270
70 8,614
SAT sensitivity, %
80 3,790
85 7,147
90 14,791
95 49,425
100 Dominated*
SAT specificity, %
68 8,162
76 8,713
84 9,264
92 9,816
100 10,367
H. pylori eradication, %
60 16,428
68.75 13,578
77.5 11,371
86.25 9,612
95 8,177
*Dominated = less effective and more cost than reference strategy.
圖 3-1. 不進行任何介入之馬可夫模型階段轉換概念圖
圖 3-2. 幽門螺旋桿菌篩檢之馬可夫模型階段轉換概念圖
圖 3-3. 馬可夫決策樹模型
圖 3-4. 不進行任何介入的馬可夫模型
圖 3-5. 碳 13 尿素呼氣試驗的馬可夫模型
圖 3-6. 幽門螺旋桿菌糞便抗原檢查的馬可夫模型
圖 4-1. 胃癌預防策略的累積效果
0 5 10 15 20 25
40 45 50 55 60 65 70 75 80 85
Effectiveness (years)
Age (years)
Cumulative Effectiveness
No intervention UBT screening SAT screening
圖 4-3. 胃癌預防策略的累積成本
0 100 200 300 400 500 600 700
40 45 50 55 60 65 70 75 80 85
Cost (US $)
Age (years)
Cumulative Cost
No intervention UBT screening SAT screening
圖 4-3. 成本效果平面圖
圖 4-4. 增量成本效果比龍捲風圖 (UBT screening vs SAT screening)
圖 4-5. 機率性敏感度分析之成本效果散佈圖
圖 4-6. 機率性敏感度分析之成本效果散佈圖 (去除無任何介入的策略)
圖 4-7. 機率性敏感度分析之增量成本效果比散佈圖 (UBT screening vs No intervention)
圖 4-8. 機率性敏感度分析之增量成本效果比散佈圖 (SAT screening vs No intervention)
圖 4-9. 機率性敏感度分析之增量成本效果比散佈圖 (UBT screening vs SAT screening)
圖 4-10. 機率性敏感度分析之可接受曲線
圖 4-11. 胃癌累積發生率
0 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04
40 45 50 55 60 65 70 75 80 85 90
Age (years)
Cumulative Incidence Rate
Crude Simulated
圖 4-12. 胃癌累積死亡率
0 0.005 0.01 0.015 0.02 0.025
40 45 50 55 60 65 70 75 80 85 90
Age (years)
Cumulative Mortality Rate
Crude Simulated
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