藥物治療疼痛的經(jīng)濟(jì)因素考慮-課件

EconomicConsiderationsinthePharmacologicManagementofPain

(藥物治療疼痛中的經(jīng)濟(jì)因素考慮）2023/9/7EconomicConsiderationsinthe1GeneralIntroductionofPain

(疼痛概論）Definition(疼痛的定義）Physicalpainisacommon,subjectiveandcomplicatedprocessthatisinitiatedbyanunpleasantsensoryexperience.Itoccursviaseveralmechanismsthatmayresultinimmobility,deconditioningandemotionalreactions.(軀體疼痛是由于不愉快的感覺經(jīng)驗(yàn)引起的一種常見的,主觀的和復(fù)雜的過程.它是通過可引起行動受限,狀態(tài)異常和情緒反應(yīng)的一系列機(jī)制而發(fā)生的.2023/9/7GeneralIntroductionofPain

2Epidemiology(流行病學(xué)資料)>75millionpeopleinU.S.havesomeformofpersistentorrecurrentpain*andpainisthemostcommonsymptomforwhichpatientsseekmedicalassistance**(在美國有超過七千五百萬人患有不同程度的持續(xù)性或反復(fù)發(fā)生的疼痛;疼痛已成為患者求醫(yī)的最常見的癥狀.在中國,130萬癌癥死亡人群中,60%以上忍受著中到重度疼痛GeneralIntroductionofPain

(疼痛概論）*CaudillM,HolmanG,TurkD.PatientCare.1996:154**FoleyK.CecilTextbookofMedicine.Philadelphia,1992:972023/9/7Epidemiology(流行病學(xué)資料)GeneralI3GreatestChallenge(偉大的挑戰(zhàn))Thegreatesthealthcarechallengeforthenextdecadeistomakethebestuseoflimitedavailableresourcestoattainthehighestqualityofhealthcareforthelowestcost.Aspharmacoeconomicdatabecomeincreasinglyavailable,theiruseincost-effectivepainmanagementandinallhealthcaredecisions,willplayamajorrole.Thepharmacistisuniquelypoisedtoadapttothisshiftingparadigm.*在下一個(gè)十年中,對健康領(lǐng)域里的最大的挑戰(zhàn)是充分利用可得到的有限資源,利用最低的花費(fèi)來得到最高的健康質(zhì)量.由于藥物經(jīng)濟(jì)學(xué)資料的增加,在疼痛控制健康項(xiàng)目決策中,其花費(fèi)和結(jié)果的研究將起主要作用.藥劑師們在適應(yīng)這場變更中起著獨(dú)一無二的平衡作用.GeneralIntroductionofPain

(疼痛概論）*MichaelRigas,EconomicConsiderationsinthePharmacologicManagementofPain.P&Ts1997:4542023/9/7GreatestChallenge(偉大的挑戰(zhàn))Gene4ClassificationofPain(疼痛的分類)TemporalClassification(時(shí)間分類)AcutePainChronicPainusuallydefinedasthatlasting6monthsorlongerthetiming,localizationandcharacterofthepainareoftenmorevague(疼痛的時(shí)間,部位和性質(zhì)經(jīng)常是含糊的)Theremaybeindicationsofsleepdisturbances,lossofappetite,decreasedlibido,weightlossanddepression.(經(jīng)常伴有睡眠干擾,食欲不振,性欲下降,體重降低及抑郁)PhysiologicClassification(生理學(xué)分類)Somatic,Visceral,Neuropathic(軀體,內(nèi)臟,神經(jīng)性)GeneralIntroductionofPain

(疼痛概論）2023/9/7ClassificationofPain(疼痛的分類)5PainManagementPrinciples(疼痛控制原則)*AcutePainpatienteducationonpostoperativepaintheneedforregularlyscheduledanalgesicsasopposedtoas-neededanalgesicsforthefirst24hoursofmoreaftersurgerytheneedforfrequentassessmentandreassessmentofpainbynursingpersonneltheneedforconsistentuseofatoolforpatientself-assessmentofpainthepossibilityofpreemptiveanalgesicstrategiesforsurgicalpatientsthespecificanalgesicstrategiesofferedtopatientsGeneralIntroductionofPain

(疼痛概論）*guidelinesandqualityassurancestandardsfromtheAgencyforHealthCarePolicyandResearch(AHCPR)2023/9/7PainManagementPrinciples(疼痛控6ChronicPainWHOanalgesicladder(WHO階梯療法)Nonopioid±AdjuvantWeakopioid±Nonopioid±AdjuvantStrongopioid±Nonopioid±Adjuvantcanprovidesatisfactorypainreliefto70-90%ofthispatientpopulation*(可使70-90%的中到重度癌痛患者得到滿意地緩解)Durogesicisthenoveladministrationwayinchronicpainrelief(多瑞吉的出現(xiàn)創(chuàng)新了慢性痛控制領(lǐng)域里的給藥途徑)GeneralIntroductionofPain

(疼痛概論）*WHOcitedinPortenoyR.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S712023/9/7ChronicPainGeneralIntroducti7PharmacologicTherapiesofPain

(疼痛的藥物治療)Theappropriateandsuccessfulmanagementofpainentailsselectionoftherightanalgesic,administeredintherightway,dosageandontherightschedulesoastomaximizepainreliefandminimize

adverseeffects.*適當(dāng)和成功的疼痛控制必需選擇正確的止痛藥物,正確的途徑和劑量以正確的時(shí)間間隔給藥,從而達(dá)到能最大緩解疼痛的同時(shí)將副作用降到最小.Estimates*InturrisiC.Managementofcancerpain:pharmacologyandprinciplesofmanagement.Cancer,1989;63:23082023/9/7PharmacologicTherapiesofPai8NonnarcoticAnalgesics(非麻醉性鎮(zhèn)痛藥)Aspirin,AcetaminophenandNSAIDs(阿斯匹林,對乙酰氨基酚及非甾體抗炎藥)firstlineagentsforthetreatmentofmild-to-moderatepain(是輕到中度疼痛的一線用藥)ceilingeffect(天花板效應(yīng))anincreaseinthedosagebeyondtherecommendedmaximumdosenotresultinanincreaseinanalgesia,andpotentiallyincreasessideeffectsnotsuitableuseforchronic,evolvingpain*(不適合用于慢性,進(jìn)展性疼痛)PharmacologicTherapiesofPain

(疼痛的藥物治療)*AshbyM.etal,Descriptionofamechanisticapproachtopainmanagementinadvancedcancer.Preliminaryreport.Pain.1992;(51):1532023/9/7NonnarcoticAnalgesics(非麻醉性鎮(zhèn)痛藥9NarcoticAnalgesics(麻醉性鎮(zhèn)痛藥)Narcoticmedicationshouldbeadministeredonaregularbasissoastomaintaintheplasmalevelofthedrugabovetheminimaleffectiveconcentrationforpainrelief.Itisnotrecommendedthatpatientswithchronicpaintakenarcoticsonanas-requiredbasis,becausewaitinguntilthepainordistressbecomesmoreseveremayactuallyexacerbatethepain.*(麻醉性鎮(zhèn)痛藥物的使用應(yīng)按時(shí)給藥,而不是按需給藥,這樣才能使藥物的血漿濃度維持在最低有效的疼痛緩解濃度之上.同時(shí),按需給藥可使疼痛更加惡化)PharmacologicTherapiesofPain

(疼痛的藥物治療)*RalphsJetal.Opiatereductioninchronicpainpatients:Pain.1994;56:2792023/9/7NarcoticAnalgesics(麻醉性鎮(zhèn)痛藥)Ph10Agonistcommonlyusedinthemanagementofchronicpain(suchascancerpain)(激動劑通常用于慢性疼痛的治療,如癌痛)Agonist-antagonistoftenusedinacutepostoperativepainmanagement,butareoflimiteduseinchronicpain(激動劑-拮抗劑通常用于急性手術(shù)后疼痛控制上,而不用于慢性疼痛的治療)PharmacologicTherapiesofPain

(疼痛的藥物治療)2023/9/7AgonistPharmacologicTherapies11AdverseeffectsofnarcoticsDespitetheprovenefficacyofnarcoticsinthemanagementofpain,thedevelopmentofadverseeffectsisalsotypicalwiththeseagents(盡管麻醉性鎮(zhèn)痛藥在疼痛控制上有確切療效,但這些藥物的不良反應(yīng)反應(yīng)也是很典型的)opioidsideeffectsdependonanumberoffactorsthatinclude:patientage,extentofdiseaseandorgandysfunction,concurrentadministrationofcertaindrugs,prioropioidexposureandtherouteofdrugadministration*(阿片類藥物不良反應(yīng)的影響因素有:年齡,疾病和器官功能受損程度,從前阿片類藥物使用狀況和給藥途徑)PharmacologicTherapiesofPain

(疼痛的藥物治療)*InturrisiC.Managementofcancerpain:pharmacologyandprinciplesofmanagement.Cancer,1989;63:23082023/9/7AdverseeffectsofnarcoticsPh12Commonadverseeffectssedation,nausea,vomiting,constipation,respiratorydepressionandtolerance(鎮(zhèn)靜;惡心;嘔吐;便秘;呼吸抑制及耐藥性)Adverseeffectsevaluationisoneoftheimportantpartsofnarcoticpharmacoeconomicevaluation(對不良反應(yīng)的評價(jià)是麻醉性鎮(zhèn)痛藥物進(jìn)行藥物經(jīng)濟(jì)學(xué)評價(jià)的重要部分之一)PharmacologicTherapiesofPain

(疼痛的藥物治療)2023/9/7CommonadverseeffectsPharmaco13AdjunctiveTherapies(輔助性治療)anticonvulsants,antidepressant,stimulants,antihistamine,phenothiazine,steroids,miscellaneous,anxiolytics(抗驚厥藥,抗抑郁藥,興奮劑,抗組胺藥,酚噻嗪,類固醇類,雜環(huán)類,抗焦慮藥)mostoftheseagentsareveryinexpensiveandtheycanbeverycost-effectivewhenappropriatelyco-prescribedtohelpcontrolpain.(大部分這類藥物非常便宜,在疼痛控制上的適當(dāng)應(yīng)用,可有很好的“效/價(jià)”比)PharmacologicTherapiesofPain

(疼痛的藥物治療)2023/9/7AdjunctiveTherapies(輔助性治療)Pha14VariousRoutesofAdministration-

AdvantagesandDisadvantages不同給藥途徑的優(yōu)缺點(diǎn)比較2023/9/7VariousRoutesofAdministrati15ProprietaryDrugsVersusGenerics

(專利藥物與仿制藥物)Theobjectiveofmakingformulariesistomaximizecost-effectivenessbyexcludingorlimitingexpensivemedicationsaslongasthequalityofcareisnotcompromised.*(制定藥物目錄的目的是在提供的健康服務(wù)質(zhì)量不受損害的情況下通過不用或限制使用昂貴藥物以使“效/價(jià)”比達(dá)到最大)*JohnsonJ,etal.Pharmacoeconomicanalysisinformularydecisions:aninternationalperspective.AmJHospPharm.1994;51:25932023/9/7ProprietaryDrugsVersusGener16NonpharmacologicApproachestoPainManagement(非藥物治療方法)Factorstobeconsideredarewhethertheinterventioneffectivelymobilizesapatient,reducestheneedforanursinghomeornursingathome,preventshospitalization,reducesideeffectsandoverallcost*(對這些治療的考慮在于其是否可明顯增加病人的活動,降低對護(hù)理的需求,減少住院,降低不良反應(yīng)和能降低總支出)PhysicalInterventions(物理療法)BehavioralInterventions(行為療法)*PortenoyR.etal.Issuesintheeconomicanalysisoftherapiesforcancerpain.Oncology.1995;9(11):S712023/9/7NonpharmacologicApproachesto17EconomicIssuesintheManagementofPain(疼痛控制中的經(jīng)濟(jì)因素)Thecostofnotmanagingaswellasmanagingchronicpainarepotentiallyveryhigh.Themorbideffectsofunrelievedpainonmoodandimmobilitycanresultinnumerousmedicalinterventions.Pain-relatedcomplications,expensivediagnosticprocedures,hospitalizationsforpaincontrolanddaysmissedfromworkcanbeextremelycostly.(不控制疼痛和對慢性疼痛的控制的花費(fèi)可能是很高的。疼痛不緩解在人的情緒和行動上的病態(tài)可導(dǎo)致相當(dāng)多的醫(yī)療問題出現(xiàn)。與疼痛有關(guān)的并發(fā)癥，昂貴的診斷手段，為控制疼痛而住院治療以及為此耽誤工作的代價(jià)都是非常高的)2023/9/7EconomicIssuesintheManagem18PrimaryIssues(主要因素)thecostofpharmacotherapy--themostimportantanalgesicapproachforcancerpain(藥物治療費(fèi)用--對于癌痛而言是最重要的止痛方法)Incorporatingpharmacoeconomicdataintotheformularydecision-makingprocess--helpsinselectingmedicationsthataresafe,effectiveandcost-efficient(將藥物經(jīng)濟(jì)學(xué)數(shù)據(jù)放入藥物目錄的評審中--這將有助于選擇出既安全有效又‘效/價(jià)’比合適的藥物)Toperformacomprehensiveevaluationofanexistingorproposedpharmaceuticalservice(對現(xiàn)有的或提議中的藥事服務(wù)進(jìn)行深入的評估是很有必要的)EconomicIssuesintheManagementofPain(疼痛控制中的經(jīng)濟(jì)因素)2023/9/7PrimaryIssues(主要因素)EconomicI19OtherIssues(其它因素)thedifferencesintreatmentsettings(治療方案的差異)theneedtojustifyservices(服務(wù)需求的調(diào)整)reimbursementbiases(報(bào)銷目錄的傾斜)thepotentialforconflictofinterest(潛在的公私利益沖突)EconomicIssuesintheManagementofPain(疼痛控制中的經(jīng)濟(jì)因素)2023/9/7OtherIssues(其它因素)EconomicIss20Pharmacoeconomics--MethodsandGuidelines

(藥物經(jīng)濟(jì)學(xué)的方法及指導(dǎo)原則)MethodsCost-minimizationAnalysisOutcomesareconsideredtobeequalandcompareonlytheimputesorcostsofeachalternativewhenefficacyandsideeffectsaresimilarCost-benefitAnalysismeasuresoutcomesindollars,Theoutcomemaybeexpressedinratioofbenefittocost,ortheratioofthedifference(netcosttobenefit),ornetcost(benefitminuscost)Cost-effectivenessAnalysismeasuresoutcomesinnonmonetaryunits(e.g.thecostperunitofsuccessoreffect--thecostperhourofreducednursingcaretimeorpermmHgchangeinBPforantihypertensivetherapy)2023/9/7Pharmacoeconomics--Methodsand21Pharmacoeconomics--MethodsandGuidelines

(藥物經(jīng)濟(jì)學(xué)的方法及指導(dǎo)原則)Cost-utilityAnalysisOutcomesexpressedinnonmonetaryunitsareadjustedforhealth-relatedqualityoflife.Cost-of-illnessAnalysisattemptstoidentifyalldirectandindirectcostsoftreatingacertaindiseaseorillness2023/9/7Pharmacoeconomics--Methodsand22BasicPrinciplestoGuidethePharmaco-economicProcess(指導(dǎo)原則)DefinetheproblemDeterminethestudy’sperspectiveDeterminethealternativesandoutcomesSelectt