【作者】 郑亚明；

【导师】 孙鹤；

【作者基本信息】 天津大学 ， 药事管理， 2012， 博士

【摘要】 由于糖尿病的经济负担不断上升，给我国的卫生领域造成了极大的影响，掌握糖尿病的经济负担十分重要。与此同时，针对糖尿病的经济负担研究间存在非常大的异质性，使得结果间无从比较判断。本研究的目的通过不同数据来源研究糖尿病及其并发症的年经负担及医疗费用，并通过不同来源的数据获得中国糖尿病的经济负担及医疗费用并深入剖析经济负担结果异质性的原因。选择北京海淀某社区及天津某三级医院通过面对面访谈的形式对符合入组条件的2型糖尿病患者进行问卷访谈，获得并对比两地2型糖尿病患者的年直接医疗费用、直接非医疗费用、间接费用和总费用。结果显示，2011年北京某社区内288名2型糖尿病患者的年直接医疗费、直接非医疗费用、间接费用和年总费用分别为18904元、909元、380元和20193元。天津某三级医院的273名2型糖尿病患者年直接医疗费、直接非医疗费用、间接费用和年总费用分别为27619元、1647元、1092元和30358元。通过分析发现，研究对象的疾病状态和就诊行为差异及研究对象的代表性均具有差异，差异原因可归结为样本选择偏倚。利用2007年天津城镇职工基本医疗保险数据库10%样本，对符合入组条件的1409名糖尿病的患者的次住院费用和年住院费用进行分析。2007年天津糖尿病平均的次均住院费用和年住院费用分别为6599元和9662元。在职与退休患者的次住院费用和年住院费用分别为7180元和8200元（在职）、6494元和10010元（退休）。在职患者的次均住院费用比退休组高，但在年住院费用上较退休组低。结果显示退休患者患病较重是年费用较在职组高的原因，而在职患者选择去高等级医院就诊则是造成次住院费较高的原因。通过对全国9城市20家二、三级医院内分泌科的医生进行问卷调查获得糖尿病主要急性并发症的发病费用及维持费用。结果显示，心肌梗塞、心绞痛、充血性心力衰竭的首年和次年费用分别为40427元和13103元、30455元和9405元、22212元和6529元。缺血性脑卒中为20799和9067元。腹膜透析、血液透析的首年及次年费用分别为50479元和41173元、72761元和61427元。周围神经病变、周围血管病变的首年和次年费用分别为14408元和5528元、21662元和8420元。低血糖和酮症酸中毒的事件费用分别为4718元和9663元。通过文献研究分析不同研究使用的研究方法、研究内容、研究对象特征等因素，总结各个因素对经济负担产生的影响，并通过影响因素分析确定出对经济负担结果具有显著性影响的因素。结果显示患者的疾病状态和经济背景对经济负担结果具有显著性影响。研究方法和内容的差异可总结归纳为研究方法的差异、研究地点、研究对象的人口学特征、疾病特征、研究的纳入与排除标准可归纳为研究对象的选择偏倚。因此通过本章内容可得到研究的方法学差异、研究对象的选择偏倚和研究的经济背景是经济负担结果产生异质性的主要原因。通过全文各章节总结可知，研究的方法学差异、研究对象的选择偏倚、研究所处的经济背景会对糖尿病经济负担产生影响，是经济负担异质性的主要原因。因此在日后的疾病负担研究中必须注意方法学差异对结果可能产生的影响。更多还原

【Abstract】 The economic burden of Diabetes Mellitus (DM) become huge and imposed greatchallenge to the healthcare system. It is critical to have a clear understanding on theeconomic burden of DM. There is great difference in the present outcomes ofeconomic studies on DM due to the heterogeneity in study design and methods. Thisstudy was to explore the economic burden and medical cost of DM with different datasources and to explore the reasons for variation in economic burden studies.The face-to-face interview was used to obtain the direct medical cost (DMC), directnon-medical cost, indirect cost (IC) and total economic burden in a community inBeijing and one tier3hospital in Tianjin. In2011,288patients with type2diabetesmellitus (T2DM) have the DMC, DNMC, IC and total cost at18904Yua n、909Yua n、380Yuan and20193Yuan per year. The economic burden for273patients withT2DM in Tianjin were27619Yua n,1647Yua n,1092Yuan and30358Yuan for DMC,DNMC and IC。The reason for difference in economic burden of the two cities wereconsidered to be the medical behavior and disease status, which could attribute to theselection bias of study population.The inpatient cost for1409patients with DM was studied with10%sample of TianjinUrban Employee Basic Medical Insurance (UEBMI) database. In2007, per admissionand the annual inpatient costs were6599and9662Yuan. The annual inpatient cost forretired DM patients were higher than the working (10010vs.8200Yuan) whereas theinpatient cost per admission for the working was higher than the retired (7180vs.6494). The severe complication status could be the reason for higher annual inpatientcost for the retired and the preference of higher tier hospitals was the reason for thehigher for the inpatient cost per admission for the working. The disease status andmedical preference were considered as the key factors of medical cost for patientswith DM.The nation-wide questionnaire survey with20internists from20tier2/3hosptials in9cities in China was to capture the event cost and state cost for DM relatedcomplications. The event and state costs for DM related complications per patientwere40427Yuan and13103Yuan for acute myocardial infarction (AMI); angina30455Yua n and9405Yua n; congestive heart failure22212Yua n and6529Yua n;ischemic stroke20799Yua n and9067Yua n; peripheral vascular disease21662Yuan and9663Yua n; neuropathy14408Yuan and5528Yua n; ESRD with haemodialysis72761Yua n and61427Yua n; ESRD with peritoneal dialysis50479Yuan and41173Yuan; severe hypoglycemic4718Yuan; ketoacidosis (DKA)9663Yua n.The systematic review of the previous literatures on economic burden of DM was toanalyze how the methods, study population, cost constitute, etc affect the economicburden and to explore the key factors to economic burden. The result shows that thedisease status and economic background were the key factors. The difference inmethod and cost constitute could explain the variation of methodology. Thedemographics, disease status and the inclusion and exclusion criteria could be theexpressed as sample selection bias. Consequently, the variation in methodology,sample selection bias, the economic background was deemed as the key influentialfactors.In conclusion, the key impact factors to the heterogeneity in economic burden of DMwere variation in methodology, sample selection bias and the economic background.Attention should be paid to the potential impact of methodology on cost-of-illnessstudies.更多还原