【作者】 杨志军；

【导师】 屠梅曾；

【作者基本信息】 上海交通大学 ， 管理科学， 2008， 博士

【摘要】 传染病是世界范围内引起死亡最多的疾病,也是我国死亡率最高的三类疾病之一。医学技术的进展使传染病的预防与控制取得了重要成果。传染病预防与治疗监测进行经济学分析对传染病防治和医学技术发展策略的制定具有重要意义。本文的目的是建立传染病预防与治疗监测经济学分析的数学模型,并分析和评估我国慢性乙型肝炎的预防和治疗监测技术的经济学影响。本文的第一章为绪论,简要介绍了本文的研究背景、研究内容和研究方法以及拟解决的关键问题。同时对文章的结构安排进行了说明。本文的第二章为文献综述,对传染病的经济负担、卫生经济学中的评估工具、慢性传染病防治技术的发展、卫生经济学中关于生产和成本研究、新技术的扩散、新技术的评价以及我国慢性传染病防治研究的现状进行了综述,完整介绍了国内外在本文相关领域的研究成果,为本文的研究提供了充分的背景资料。本文第三章建立了模拟传染病扩散和估算我国慢性传染病经济负担的数学模型。传染病扩散模型可以估算人群中感染者、易感染和健康者的数量,估算传染病经济负担的模型可以根据感染者所处的不同疾病状态的直接和间接成本估算出疾病负担。据此估算的我国2007年慢性乙型肝炎的直接医疗成本高达367亿元人民币。如果不进行免疫预防,我国2007年出生的人口在将来造成的经济损失高达1154亿元人民币。在此之前,本章还分析了我国经济法发展与传染病控制的相关关系。第四章建立了分析疫苗免疫技术经济学影响的数学模型,并对我国乙型肝炎疫苗免疫的经济学影响进行分析和评价。根据最新公布的慢性乙肝调查数据,通过成本-效果分析、成本-效益分析和成本-效用分析,证明疫苗免疫的经济效果非常显著,每年可以节约50多亿元人民币的治疗费。第五章建立数学模型对慢性传染病治疗监测进行经济学分析和评价。建立了确定最佳耐药检测时间的数学模型、确定定性检测条件下更换治疗方案的最优策略的数学模型、确定定量检测条件下更换治疗方案的最优策略的数学模型以及不同检测方法比较评价的数学模型。确定拉米夫定耐药监测时间间隔,分析和评估拉米夫定耐药检测经济学影响,发现如果采用慢性乙型肝炎治疗监测手段,每年可以节约治疗费用5亿多元人民币。最后一章给出本文的如下结论:(1)现阶段我国传染病发病率与国内生产总值和国家财政支出呈显著负相关,病死率与农村恩格尔系数呈显著正相关;(2)我国慢性传染病的经济负担非常沉重,采用疫苗预防具有很高的经济效果;(3)采用本文建立的马尔科夫决策模型和增量成本效果分析模型可以对慢性传染病的预防与治疗监测进行经济学分析和评价;(4)我国慢性乙型肝炎的经济负担十分严重,采用疫苗免疫和合适的治疗监测可以节约大量治疗费用。文章的最后根据研究结果提出了对我国传染病防治与医学技术发展的政策建议。本文的主要创新之处卫生技术经济学分析的研究在我国处于刚刚起步阶段,有许多理论和实践的具体问题需要探索和研究。本论文针对我国慢性传染性疾病的预防和控制的特点,建立评估我国传染病经济负担的数学模型、评价传染病预防技术及策略的数学模型和评价传染病治疗监测的数学模型,同时详细估算了我国慢性乙型肝炎的经济负担、预防技术和策略的经济学影响和治疗监测技术的经济学影响。主要创新点有以下几个方面:1、建立了确定慢性传染病治疗监测最优策略的数学模型:国内外的研究人员虽然对疾病负担、预防技术、诊断技术和治疗技术的评估进行了广泛研究,但对治疗监测技术的经济学分析缺乏深入研究,这可能与治疗监测技术仅仅在最近几年才得到迅速发展有关。本论文应用马尔可夫决策方法建立了确定慢性传染病治疗监测最优策略的数学模型,为更加有效地治疗慢性传染性疾病、降低医疗费用和节约卫生资源提供了理论依据。2、建立了确定慢性传染病最佳治疗监测时间的数学模型:虽然对慢性传染病的治疗效果进行监测已经成为临床专家的共识,但目前对治疗监测时间的确定仍然基于专家的经验判断,缺乏理论上的支持。本论文采用决策分析方法,建立了确定慢性传染病最佳治疗监测时间的数学模型,为慢性传染病的治疗监测提供了理论依据。3、建立了对慢性传染病治疗监测技术进行经济学分析的数学模型:治疗监测技术是近几年发展起来的基于药物基因组学的新技术,其临床应用的范围日益扩大,但对其进行经济学分析的研究尚未见报道。本文采用成本-效益分析方法建立了对治疗监测技术进行经济学评价的模型,为进一步研究慢性疾病治疗监测策略的经济学意义奠定了基础。4、系统分析了我国慢性乙型肝炎的经济负担、预防技术和策略的经济学影响以及慢性乙型肝炎治疗监测技术的经济学影响:我国是慢性乙型肝炎重负担国家,但目前仍缺乏对我国慢性乙型肝炎的经济负担估算的系统研究。对免疫预防技术的评估也仅限于城市区域,对慢性乙型肝炎治疗监测技术的经济学分析的研究尚未见报道。本文采用我国2006年慢性乙型肝炎全国普查的最新资料(本资料于2008年4月21日公布)对我国慢性乙型肝炎的经济负担进行估算,并根据我国乙型肝炎免疫规划分析疫苗免疫接种的经济学影响,同时还对目前的慢性乙型肝炎治疗监测策略进行经济学分析和评价,为我国慢性乙型肝炎的预防和控制决策提供了具体的资料。更多还原

【Abstract】 Infectious diseases cause enormous morbidity and mortality world wide. In China, infectious diseases are the third most frequent cause of death. Development of medical technologies results in important progress in infectious disease prevention and control. For decisions on the prevention and control of the infectious disease as well as development of medical technologies, it is of importance to analyze the economic impact of the prevention and control of infectious diseases. The aim of this study was to establish mathematical models to analyze the economic impact of the prevention and control of infectious diseases, taking chronic hepatitis B in China for an example.In Chapter 1, The background, contents, methodologies, and key issues in this study were introduced. The structure of this study was also demonstrated in this chapter.In Chapter 2, The recent literatures in the fields related to this study were reviewed. The review covered the issues of economic burdens of infectious diseases, evaluation tools in the health economics, technology improvement in the prevention and treatment of infectious diseases, production and costs in health industry, diffusion of new technologies, evaluation of new technologies, and current status of the prevention and control of infectious diseases in China. This review provided sufficient background data for this study.In Chapter 3, Models to analyze the spread of infectious diseases and the disease burden of chronic infectious diseases were established, respectively. The models were able to estimate the numbers of infected, susceptible, and healthy individuals in a certain population, as well as the economic burden of the infectious disease. The estimated direct economic burden of China in the year of 2007 was 36.7 billion RMB. Without immunization programme, the birth cohort of China in 2007 would result in a loss of 115.4 billion RMB in their future lives. Besides, the relation between economy development and incidence of infectious diseases was analyzed in this chapter.In Chapter 4, A model to analyze the economic impact of vaccine immunization was developed. Using the newly published data of a survey on chronic hepatitis B covering the whole China, we analyzed the economic impact of hepatitis B vaccine immunization in China by the tools of cost-effect analysis, cost-benefit analysis, and cost-utility analysis. The results showed that hepatitis B vaccine immunization in China had a great economic effect and saved 5 billion RMB direct medicare costs annually.In Chapter 5, Models to evaluate the economic impact of technologies for monitoring therapies, including a model for determination of the best timing of monitoring, models for selection of best strategy when quantitative or qualitative technologies were used for monitoring the therapy, and a model for comparison of different monitoring strategies were established. These models were used to determine the best timing for monitoring lamivudine therapy in chronic hepatitis B patients, and revealed that monitoring of lamivudine-resistance by new medical technology would save 500 million RMB annually.In the last chapter the following conclusions were reached: 1) Currently, the incidence of infectious diseases is correlated significantly with the Gross Domestic Product (GDP) and the public expenditure, while the death per 100 patients is significantly correlated with rural Engel’s coefficient; 2) China has a great economic burden of infectious diseases, and universal vaccine immunization is a cost effective strategy for prevention of the infectious diseases; 3) Using Markov decision models and incremental cost-effective models established in this study is able to analyze and estimate the economic burden of diseases and the impact of medical technologies; 3) China has a very great economic burden of chronic hepatitis B. Universal vaccine immunization and monitoring of therapy will significantly save the health care costs.We also made comments on the policies about the prevention and control of infectious diseases and the development of medical technologies.Innovations in this studyStudies on the economic analysis of health care technologies are in its infancy here in China, and many theoretical and practical issues need to be explored. This study provided mathematical models in accordance with the features of infectious diseases to analyze and evaluate the economic burden of infectious diseases, technologies and strategies for prevention and treatment monitoring of infectious diseases. Taking chronic hepatitis B as an example, we estimated the economic burden, economic effects of prevention technologies and strategies, and economic impact of the treatment monitoring technologies and strategies. The major innovations in this study are as following:1, Establishment of mathematical models for determination of the optimal strategy for monitoring of the treatment of chronic infectious diseases. Markov decision models were established in this study to optimize strategies for monitoring the drug resistance during treatment of chronic infectious diseases. This will be helpful for effective treatment of infectious diseases and reduce of the health care costs.2, Establishment of mathematical models for determination of optimal timing for treatment monitoring. Currently, the time of initiation and intervals of treatment monitoring is based on the experiences of clinical physicians. Decision models established in this study may be used for determination of the optimal intervals of monitoring during treatment of chronic infectious diseases.3, Establishment of mathematical models for economic analysis of treatment monitoring of chronic infectious diseases. Treatment monitoring technologies are newly developed technologies based on the pharmacogenomics. A incremental cost-effective analysis model was established in this study for economic evaluation of the monitoring technologies during treatment of chronic infectious diseases.4, Systematic analysis of the economic burden, the economic impacts of prevention and treatment monitoring technologies and strategies of chronic hepatitis B infection in China. China has very great economic burden of hepatitis B infection in the world. However, studies on the economic burden of this disease in China are limited. In this study, based on the newly published data on chronic hepatitis B in China, we systematically estimated the economic burden of chronic hepatitis B in China, analyzed the economic effects of universal immunization programme of hepatitis B vaccine, and evaluated the economic impact of monitoring of treatment of chronic hepatitis B. This will put new insight into the prevention and control of chronic hepatitis B in China.更多还原