【作者】 周栋；

【导师】 赵淮； 郭涛； 刘中梅； 赵玲； 李淑敏；

【作者基本信息】 昆明医学院 ， 内科学， 2008， 硕士

【摘要】 【目的】研究我国目前心脏起搏治疗费用;从卫生经济学角度对心脏起搏治疗进行评估,合理利用我国卫生资源;提高患者长期生存质量。【方法】收集2004年10月1日至2007年12月31日在昆明医学院第一附属医院由心内科完成各种永久心脏起搏器植入术并符合纳入标准405例患者,记录基本情况、植入起搏器种类、治疗及手术费用支出项目、医疗付款方式、基础疾病情况、心功能分级、生活质量评分等相关临床资料及指标,随访患者接受心脏起搏后6个月生活质量评分改变情况、后续费用情况、近期及远期并发症情况。【结果】接受心脏起搏治疗前后生活质量有显著改变。除1例VVI患者术后3月因非心脏性原因(脑卒中)死亡外,404例患者生活质量均显著提高,不同类型改变程度有显著差别,AAI、DDD优于VVI。28例接受ICD或CRT-D植入患者未发生猝死。植入CRT和CRT-D患者术后1月生活质量及症状体征提示心功能显著改善。初次植入永久起搏器直接费用:VVI为(3.12±1.50)万元,DDD为(4.88±1.92)万元,ICD为(8.05±3.95)万元,CRT为(10.22±1.09)万元,CRT-D为(20.31±10.54)万元。起搏器费用占直接费用比例:VVI(79.25±2.55)%,DDD(82.17±7.02)%,CRT(86.80±6.94)%,ICD(79.32±6.55)%,CRT-D(83.24±8.11)%。永久起搏器更换费用:AAI平均(2.89±0.04)万元,VVI平均(2.63±0.58)万元,DDD平均(3.82±1.79)万元,CRT平均(10.46±0.85)万元,CRT-D平均(20.59±1.11)万元,单腔ICD平均(6.85±2.15)万元。起搏器均为进口起搏器。405例患者中接受VVI起搏器共175例,接受AAI永久起搏器共2例,接受DDD起搏器共183例,接受CRT起搏器共17例,接受CRT-D共6例,接受单腔ICD植入22例。323例为确诊后初次植入起搏器,82例为再次更换起搏器。405例中城镇职工基本医疗保险219人,公费医疗20人,自费166人。生理性起搏(AAI、VVIR、DDD、DDDR)185例(45.68%)。病因:病态窦房结综合症169例,高度房室传导阻滞171例,因窦房结和房室结双结病变19例,血管迷走神经性晕厥1例,扩张性心肌病23例,阵发性室速/室颤22例。初次植入永久心脏永久起搏器323人,大于60岁270人,为接受心脏起搏主体。男性初次心脏起搏治疗平均年龄(68.08±12.78)岁,女性初次心脏起搏治疗平均年龄(65.50±14.21)岁。405例有4例术后30天内电极脱位;2例术后1周内发生囊袋感染;1例术后7年发生起搏器综合症。82例永久起搏器更换患者,平均永久起搏器使用年限AAI(9.80±0.14)年,VVI(9.07±0.70)年,DDD(7.72±0.81)年,ICD为(5.70±0.55)年,CRT(5.42±0.13)年,CRT-D(5.11±0.08)年。【结论】1.心脏起搏治疗存在严重过缓性和(或)快速性心律失常患者具有提高生存率、改善生存质量、减少住院率、提高劳动能力等强大优势,并且显效快、更换容易、随访简便,应大力在中国推广普及。2.进一步完善医疗保障制度,扩大医疗保险人群,可使更多人群获益于心脏起搏。3.通过研制开发我国有自主知识产权的心脏起搏器降低治疗成本、增强我国经济实力有利于推广心脏起搏。4.临床严格把握适应症,因病施治,降低并发症发生率,通过动态优化起搏系统延长起搏寿命有助于心脏起搏治疗卫生经济学改观。更多还原

【Abstract】 Objective To study the cost of Cardiac Pacemaker now in our country.To evaluate the therapy of cardiac pacing by medical economics,use the limited health resources reasonablly and elevate patient’s long term survival quality.Method To collect 405 postoperation patient’s data in which the pacers were implanted by cardiac medical department,all these patients were correspond to the selected standard.To record the patients’ basic condition,the type of pacer,the cost of treatment and operation,the pay way of cost,the condition of the basic disease, the cardiac functional grading,the score of quality of life et al.To follow up the change of the score of quality of life 6 months later,the continued cost,the complication of short-term and long-term.Results The patients who accepted the operation of implanting pacer have gotten the obvious improvement in the quality of life.404 patients’ quality of life have been improved obviously besides 1 patient died from non-cardiac reason(stroke),but the change is different in different type of pacer and AAI,DDD are better than VVI. Nobody died from sudden death in 28 patients who accepted ICD or CRT-D.The patients’ quality of life,symptom and physical sign postoperation 1 moth later demonstrate the patients’ heart function has improved obviously.All cost of the patients who accepted implanting of pacer:VVI is￥(3.12±1.50)×10~4,DDD is￥(4.88±1.92)×10~4,ICD is￥(8.05±3.95)×10~4,CRT is￥(10.22±1.09)×10~4,CRT-D is￥(20.31±10.54)×10~4.The average percent of pacer in all direct cost:VVI is (79.25±2.55)%,DDDis(82.17±7.02)%,CRT is(86.80±6.94)%,ICD is (79.32±6.55)%,CRT-D is(83.24±8.11)%.The average cost of replacement: AAI is￥(2.89±0.04)×10~4,VVI is￥(2.63±0.58)×10~4,DDD is￥(3.82±1.79)×10~4,CRT is￥(10.46±0.85)×10~4,CRT-D is￥(20.59±1.11)×10~4,ICD is￥(6.85±2.15)×10~4.All 405 pacemakers are imported from foreign countries.In 405 pacemakers,there are 175 VVI-pacemkers,2 AAI-pacemakers,183 DDD-pacemakers,17 CRT-pacemakers,6 CRT-Ds,22 ICDs.After final diagnosis, there are 323 patients who accepted implanting for the first time,82 patients who have been replaced for one or more times.219 patients enjoy the society basic medical insurance,20 patients enjoy state medicine and 166 patients are at their own expense.There are 185 physiological pacmaker,including AAI,VVIR,DDD, DDDR,in 405 patients.169 patients are implanted pacmaker because of SSS,171 are implanted because of AVB,19 are implanted because of binodal disease,1 is implanted because of nervous apopsychia,23 are implanted CRT or CRT-D because of DCM,22 are implanted ICD because of VT/VF.In 323 patients who accepted implanting for the first time,there are 270 patients who are over 60 years old and they are the main body who accepted implanting.For the implanting of the first time, the man’s mean age is(68.08±12.78),the woman’s mean age is(65.50±14.21). There are 4 patients who have happened loose electrode placement,2 patients who have happened pocket infection within 1 moth,1 VVI-patient happened PMS.The mean use age in 82 patients who experienced recovered pacemaker:AAI is (9.80±0.14),VVI is(9.07±0.70),DDD is(7.72±0.81),ICD is(5.70±0.55),CRT is (5.42±0.13),CRT-D is(5.11±0.08).Conclusion①There are powerful odds that the cardiac pacing elevate survival rate,improve quality of life,diminish hospitalization rate,boost physical working capacity to treat the bradyarrhythmia and tachyarrhythmia.Cardiac pacing also have the forte of rapid excellence,easy replacement.Cardiac pacing should be generalized and pervasion..②More and more people will benefit in cardiac pacing by the consummate system of medical care assurance and extending people of medical care assurance.③It is useful for generalizing the cardiac pacing to cut down the cost price of cardiac pacing by manufacturing and developping pacemaker which has the Chinese intellectual property rights and enhancing economic strength of our country.④It is helpful for improving the appearance of medical economics in cardiac pacing to grasp clinical indication of cardiac pacing strictly,lower incidence of complication and prolong serviceable life of pacer by optimizing the pacing system dynamicly.更多还原