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Article(id=1321169983393083951, tenantId=1146029695717560320, journalId=1319373219989389464, issueId=1321169924697993338, articleNumber=null, orderNo=null, doi=10.11847/zgggws1145119, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1717430400000, receivedDateStr=2024-06-04, revisedDate=1734883200000, revisedDateStr=2024-12-23, acceptedDate=1744387200000, acceptedDateStr=2025-04-12, onlineDate=1792921070192, onlineDateStr=2026-10-25, pubDate=1746806400000, pubDateStr=2025-05-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1792921070192, onlineIssueDateStr=2026-10-25, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1792921070192, creator=13701087609, updateTime=1792921070192, updator=13701087609, issue=Issue{id=1321169924697993338, tenantId=1146029695717560320, journalId=1319373219989389464, year='2025', volume='41', issue='5', pageStart='513', pageEnd='640', issueExtLink='null', onlineDate='null', pubDate='1746806400000', pubDateStr='2025-05-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1792921056198, creator='13701087609', updateTime=1792921056198, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=557, endPage=561, ext={EN=ArticleExt(id=1321169983602799152, articleId=1321169983393083951, tenantId=1146029695717560320, journalId=1319373219989389464, language=EN, title=Health economic evaluation of community-based diabetic retinopathy screening among type 2 diabetes mellitus patients in Shenzhen, China: a Markov model simulation study, columnId=1321169943039693150, journalTitle=Chinese Journal of Public Health, columnName=Special Report–Healthy Living for Chronic Disease Prevention, runingTitle=null, highlight=null, articleAbstract=
Objective

To conduct a health economic evaluation of a community-based screening strategy for diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM) in Shenzhen, Guangdong Province, and to provide evidence for implementation of this screening strategy in primary healthcare facilities in the city.

Methods

Community-based DR screening was conducted from August to December 2021 among 1200 T2DM patients recruited from 10 administrative districts in Shenzhen using a two-stage random sampling approach. A Markov model was constructed from a health care services perspective to conduct a cost-effectiveness analysis of the community-based DR screening strategy, with community-based DR screening as the intervention strategy and no screening as the control. Costs, effect sizes, and incremental cost-effectiveness ratios (ICERs) were estimated. Univariate and probabilistic sensitivity analyses were performed to assess the robustness of the results.

Results

Of the 1 097 participants finally included in the analysis, 266 (24.3%) were diagnosed with DR. Through 20 simulated cycles of systematic screening, the control (no screening) and intervention (screening) groups incurred costs of Chinese Yuan (CNY) 38 882.05 and CNY 41 920.75, respectively, and gained 17.13 and 17.42 quality adjusted life years (QALYs), respectively. The incremental cost-effectiveness ratio (ICER) was CNY 10 478.28/QALY. The net monetary benefits were CNY 218 071.06 and CNY 219 409.58 for the control and intervention groups, respectively, with a benefit-cost ratio of 5.23 for the screening strategy (indicating an indirect return of CNY 5.23 per CNY 1 invested). After 20 simulation cycles, the blindness rate was 21.0% (no screening) versus 10.1% (screening), with screening preventing approximately 120 cases of DR-related blindness in T2DM patients. Sensitivity analyses identified the health utility of blind patients and the annual cost of DME treatment as the most influential parameters. Probabilistic analysis showed good willingness-to-pay (WTP) among T2DM patients in Shenzhen, with screening being cost-effective at WTP thresholds > CNY 10 478.28/QALY.

Conclusions

The results demonstrate that the community-based DR screening strategy for T2DM patients in Shenzhen City is cost-effective and can be promoted in primary healthcare facilities in similar urban settings.

, authors=Ziyang ZHANG, Chongwei ZHANG, Yali LIN, Jingwen YU, Xiaobing WU, authorsList=Ziyang ZHANG, Chongwei ZHANG, Yali LIN, Jingwen YU, Xiaobing WU, authorCompany=null, correspAuthors=Xiaobing WU, authorNote=null, correspAuthorsNote=
WU Xiaobing, E-mail:
, copyrightStatement=Copyright © 2025 Chinese Journal of Public Health. All rights reserved., copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1321169985767060021, articleId=1321169983393083951, tenantId=1146029695717560320, journalId=1319373219989389464, language=CN, title=深圳市2型糖尿病患者糖尿病视网膜病变社区筛查策略卫生经济学评价, columnId=1321169943232631136, journalTitle=中国公共卫生, columnName=专题报道——健康生活方式，预防慢性病, runingTitle=null, highlight=null, articleAbstract=
目的

对广东省深圳市2型糖尿病（T2DM）患者糖尿病视网膜病变（DR）社区筛查策略进行卫生经济学评价，为该筛查策略在深圳市基层医疗卫生机构的推广提供参考依据。

方法

于2021年8—12月采用两阶段随机抽样方法在深圳市10个行政区中抽取1 200例T2DM患者进行DR社区筛查，并以DR社区筛查为研究策略、不筛查为对照策略，从医疗卫生服务角度构建Markov模型对深圳市DR社区筛查策略进行成本效益分析，估算其成本、效益值和增量成本效益比（ICER），并通过单因素敏感性分析和概率敏感性分析评估结果的稳定性。

结果

本研究最终对深圳市1 097例T2DM患者进行DR社区筛查，其中患DR者266例，DR患病率为24.3%；通过模拟20个周期进行系统性筛查，不筛查组和筛查组的成本分别为38 882.05和41 920.75元，可分别获得17.13和17.42个质量调整生命年（QALY），ICER值为10 478.28元/QALY；对筛查策略下的收益及成本进行比较，不筛查组和筛查组的净效益（NMB）分别为218 071.06和219 409.58元，DR社区筛查策略的效益成本比（BCR）为5.23，在本筛查策略下每投入1元成本可获益5.23元的间接货币收益；不筛查组和筛查组经过20个周期模拟后失明例数的比例分别为21.0%和10.1%，DR社区筛查约可挽救120例T2DM患者免于因DR导致的失明；单因素敏感性分析结果显示，对ICER影响最大的健康效益值参数和成本参数分别为失明患者的健康效益值和并发糖尿病视黄斑水肿（DME）患者的年治疗成本；概率敏感性分析结果显示，深圳市居民对DR社区筛查具有良好的支付意愿，且DR筛查在支付意愿阈值>10 478.28元/QALY的情况下可带来远大于采取不筛查策略时的收益。

结论

深圳市DR社区筛查策略具有良好的经济学效益，可在深圳市基层医疗机构进行推广。

, authors=张紫阳, 张崇威, 林雅粒, 虞静雯, 吴肖冰*, *, authorsList=张紫阳, 张崇威, 林雅粒, 虞静雯, 吴肖冰, authorCompany=null, correspAuthors=吴肖冰, authorNote=

张紫阳（1988—），主管医师，硕士，研究方向：慢性病预防与控制

, correspAuthorsNote=
吴肖冰，E-mail：
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A global assessment of eye health and quality of life: a systematic review of systematic reviews[J]. JAMA Ophthalmology, 2021, 139(5): 526-541., articleTitle=null, refAbstract=null), Reference(id=1321169991479702130, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=17, rfOrder=16, authorNames=null, journalName=null, refType=null, unstructuredReference=Huang X M, Yang B F, Zheng W L, et al. Cost-effectiveness of artificial intelligence screening for diabetic retinopathy in rural China[J]. 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Perceived diabetes risk and related determinants in individuals with high actual diabetes risk: results from a nationwide population-based survey[J]. BMJ Open Diabetes Research and Care, 2019, 7(1): e000680., articleTitle=null, refAbstract=null), Reference(id=1321169991748137590, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=21, rfOrder=20, authorNames=null, journalName=null, refType=null, unstructuredReference=Zhang Z Y, LÜ D L, You Y Y, et al. Assessing the importance of risk factors for diabetic retinopathy in patients with type 2 diabetes mellitus: results from the classification and regression tree models[J]. Journal of Family and Community Medicine, 2024, 31(3): 197-205., articleTitle=null, refAbstract=null), Reference(id=1321169991823635063, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, doi=null, pmid=null, pmcid=null, year=null, volume=null, issue=null, pageStart=null, pageEnd=null, url=null, language=null, rfNumber=22, rfOrder=21, authorNames=null, journalName=null, refType=null, unstructuredReference=魏李芳, 张玲, 谭娅, 等. 慢性病共病患者社区卫生服务的选择偏好研究[J]. 中国全科医学, 2024, 27(4): 454-459, 467., articleTitle=null, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1321169986006135350, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, xref=null, ext=[AuthorCompanyExt(id=1321169986014523959, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, companyId=1321169986006135350, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Shenzhen Center for Chronic Disease Control, Shenzhen 518000, China), AuthorCompanyExt(id=1321169986022912568, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, companyId=1321169986006135350, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=深圳市慢性病防治中心，深圳 518000)])], figs=[ArticleFig(id=1321169988023595612, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=EN, label=Fig.1, caption=State transition diagram of diabetic retinopathy in the Markov model, figureFileSmall=5I5NkxvA4xifqfZc9VJygw==, figureFileBig=YO0Mp8ZrJUFA9hAal/ALWA==, tableContent=null), ArticleFig(id=1321169988094898781, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=CN, label=图1, caption=Markov模型结构, figureFileSmall=5I5NkxvA4xifqfZc9VJygw==, figureFileBig=YO0Mp8ZrJUFA9hAal/ALWA==, tableContent=null), ArticleFig(id=1321169988266865246, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=EN, label=Fig.2, caption=Tornado plot for one-way deterministic sensitivity analysis of 16 parameters on health utility value and disease treatment costs in the Markov model, figureFileSmall=sUBXEqLd4kMebJnjLqNSkg==, figureFileBig=Z7d9nGzub0XK0q2DnVmKgQ==, tableContent=null), ArticleFig(id=1321169989923615327, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=CN, label=图2, caption=单因素敏感性分析, figureFileSmall=sUBXEqLd4kMebJnjLqNSkg==, figureFileBig=Z7d9nGzub0XK0q2DnVmKgQ==, tableContent=null), ArticleFig(id=1321169990011695712, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=EN, label=Tab.1, caption=

Name, base case value, range, and source of forty input parameters across five dimensions in the Markov model

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参数项目参数值敏感度分析范围数据来源
流行病学参数mNPDR患病率0.212 00.189～0.238现场调查
cNPDR患病率0.024 00.016～0.035现场调查
PDR患病率0.006 00.003～0.013现场调查
DR状态转移概率无DR-mNPDR0.055 00.038～0.079参考文献[7]
无DR-cNPDR0.007 00.004～0.013参考文献[7]
无DR-PDR0.004 00.002～0.009参考文献[7]
无DR-DME0.013 00.010～0.017参考文献[7]
mNPDR-cNPDR0.023 00.012～0.041参考文献[9]
mNPDR-PDR0.006 00.001～0.018参考文献[10]
mNPDR-DME0.026 00.021～0.032参考文献[11]
cNPDR-PDR（筛查组）0.053 90.000 0～0.110 0参考文献[12]
cNPDR-PDR（非筛查组）0.110 00.083～0.138参考文献[12]
cNPDR-DME0.016 00.010～0.050参考文献[13]
PDR-DME（筛查组）0.022 00.017～0.028参考文献[13]
PDR-DME（非筛查组）0.032 00.024～0.040参考文献[13]
PDR–失明（筛查组）0.020 00.018～0.022参考文献[14]
PDR失明（非筛查组）0.090 00.081～0.099参考文献[14]
DME–失明（筛查组）0.030 00.005～0.065参考文献[14]
DME–失明（非筛查组）0.050 00.037 5～0.062 5参考文献[14]
健康效用值参数无DR1.000 00.75～1.25参考文献[15]
mNPDR0.980 00.96～0.99参考文献[15]
cNPDR0.850 00.82～0.89参考文献[15]
PDR0.553 00.442～0.665参考文献[15]
DME0.553 00.442～0.665参考文献[15]
失明0.350 00.000～0.768参考文献[15]
医疗资源使用/%cNPDR/PDR行全视网膜光凝术的比例100.000 050～150参考文献[16]
cNPDR/PDR注射血管内皮生长因子的比例80.000 040～12参考文献[16]
全视网膜光凝术后需再行全视网膜光凝术的比例42.000 021～63参考文献[16]
全视网膜光凝术后行玻璃体切除术的比例8.130 06.10～10.16参考文献[16]
医疗资源消耗成本贴现率0.030 00.02～0.04参考文献[16]
免散瞳眼底照相/（元/双眼）56.000 028.00～84.00现场调查
印刷宣传及培训/（元/人）16.000 08.00～24.00现场调查
督导及病例管理/（元/人）4.000 02.00～6.00现场调查
T2DM年治疗成本/（元/年）1 182.500 0591.25～1 773.75参考文献[16]
T2DM合并DR年治疗成本/（元/年）2 129.100 01 064.55～3 193.65参考文献[6]
T2DM合并DME年治疗成本/（元/年）6 329.800 03 164.9～9 494.7参考文献[16]
全视网膜光凝术/（元/组）2 000.000 01 000.00～3 000.00参考文献[16]
血管内皮生长因子注射治疗/（元/针）3 950.000 01 975.00～5 925.00参考文献[16]
玻璃体切除术/（元/次）20 000.000 010 000.00～30 000.00参考文献[16]
失明所致直接医疗费用/（元/人）33 023.000 016 511.50～49 534.50参考文献[16]
), ArticleFig(id=1321169990087193185, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321169983393083951, language=CN, label=表1, caption=

Markov模型参数及其来源

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参数项目参数值敏感度分析范围数据来源
流行病学参数mNPDR患病率0.212 00.189～0.238现场调查
cNPDR患病率0.024 00.016～0.035现场调查
PDR患病率0.006 00.003～0.013现场调查
DR状态转移概率无DR-mNPDR0.055 00.038～0.079参考文献[7]
无DR-cNPDR0.007 00.004～0.013参考文献[7]
无DR-PDR0.004 00.002～0.009参考文献[7]
无DR-DME0.013 00.010～0.017参考文献[7]
mNPDR-cNPDR0.023 00.012～0.041参考文献[9]
mNPDR-PDR0.006 00.001～0.018参考文献[10]
mNPDR-DME0.026 00.021～0.032参考文献[11]
cNPDR-PDR（筛查组）0.053 90.000 0～0.110 0参考文献[12]
cNPDR-PDR（非筛查组）0.110 00.083～0.138参考文献[12]
cNPDR-DME0.016 00.010～0.050参考文献[13]
PDR-DME（筛查组）0.022 00.017～0.028参考文献[13]
PDR-DME（非筛查组）0.032 00.024～0.040参考文献[13]
PDR–失明（筛查组）0.020 00.018～0.022参考文献[14]
PDR失明（非筛查组）0.090 00.081～0.099参考文献[14]
DME–失明（筛查组）0.030 00.005～0.065参考文献[14]
DME–失明（非筛查组）0.050 00.037 5～0.062 5参考文献[14]
健康效用值参数无DR1.000 00.75～1.25参考文献[15]
mNPDR0.980 00.96～0.99参考文献[15]
cNPDR0.850 00.82～0.89参考文献[15]
PDR0.553 00.442～0.665参考文献[15]
DME0.553 00.442～0.665参考文献[15]
失明0.350 00.000～0.768参考文献[15]
医疗资源使用/%cNPDR/PDR行全视网膜光凝术的比例100.000 050～150参考文献[16]
cNPDR/PDR注射血管内皮生长因子的比例80.000 040～12参考文献[16]
全视网膜光凝术后需再行全视网膜光凝术的比例42.000 021～63参考文献[16]
全视网膜光凝术后行玻璃体切除术的比例8.130 06.10～10.16参考文献[16]
医疗资源消耗成本贴现率0.030 00.02～0.04参考文献[16]
免散瞳眼底照相/（元/双眼）56.000 028.00～84.00现场调查
印刷宣传及培训/（元/人）16.000 08.00～24.00现场调查
督导及病例管理/（元/人）4.000 02.00～6.00现场调查
T2DM年治疗成本/（元/年）1 182.500 0591.25～1 773.75参考文献[16]
T2DM合并DR年治疗成本/（元/年）2 129.100 01 064.55～3 193.65参考文献[6]
T2DM合并DME年治疗成本/（元/年）6 329.800 03 164.9～9 494.7参考文献[16]
全视网膜光凝术/（元/组）2 000.000 01 000.00～3 000.00参考文献[16]
血管内皮生长因子注射治疗/（元/针）3 950.000 01 975.00～5 925.00参考文献[16]
玻璃体切除术/（元/次）20 000.000 010 000.00～30 000.00参考文献[16]
失明所致直接医疗费用/（元/人）33 023.000 016 511.50～49 534.50参考文献[16]
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深圳市2型糖尿病患者糖尿病视网膜病变社区筛查策略卫生经济学评价
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张紫阳 , 张崇威 , 林雅粒 , 虞静雯 , 吴肖冰 *, *
中国公共卫生 | 专题报道——健康生活方式，预防慢性病 2025,41(5): 557-561
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中国公共卫生 |专题报道——健康生活方式，预防慢性病 2025 , 41 (5) : 557 -561
深圳市2型糖尿病患者糖尿病视网膜病变社区筛查策略卫生经济学评价
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张紫阳, 张崇威, 林雅粒, 虞静雯, 吴肖冰*, *
作者信息
  • 深圳市慢性病防治中心，深圳 518000
通讯作者:
吴肖冰，E-mail：
作者简介:

张紫阳（1988—），主管医师，硕士，研究方向：慢性病预防与控制

Health economic evaluation of community-based diabetic retinopathy screening among type 2 diabetes mellitus patients in Shenzhen, China: a Markov model simulation study
Ziyang ZHANG, Chongwei ZHANG, Yali LIN, Jingwen YU, Xiaobing WU
Affiliations
  • Shenzhen Center for Chronic Disease Control, Shenzhen 518000, China
    • Corresponding Author:
    WU Xiaobing, E-mail:
出版时间: 2025-05-10 doi: 10.11847/zgggws1145119
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摘要
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目的

对广东省深圳市2型糖尿病（T2DM）患者糖尿病视网膜病变（DR）社区筛查策略进行卫生经济学评价，为该筛查策略在深圳市基层医疗卫生机构的推广提供参考依据。

方法

于2021年8—12月采用两阶段随机抽样方法在深圳市10个行政区中抽取1 200例T2DM患者进行DR社区筛查，并以DR社区筛查为研究策略、不筛查为对照策略，从医疗卫生服务角度构建Markov模型对深圳市DR社区筛查策略进行成本效益分析，估算其成本、效益值和增量成本效益比（ICER），并通过单因素敏感性分析和概率敏感性分析评估结果的稳定性。

结果

本研究最终对深圳市1 097例T2DM患者进行DR社区筛查，其中患DR者266例，DR患病率为24.3%；通过模拟20个周期进行系统性筛查，不筛查组和筛查组的成本分别为38 882.05和41 920.75元，可分别获得17.13和17.42个质量调整生命年（QALY），ICER值为10 478.28元/QALY；对筛查策略下的收益及成本进行比较，不筛查组和筛查组的净效益（NMB）分别为218 071.06和219 409.58元，DR社区筛查策略的效益成本比（BCR）为5.23，在本筛查策略下每投入1元成本可获益5.23元的间接货币收益；不筛查组和筛查组经过20个周期模拟后失明例数的比例分别为21.0%和10.1%，DR社区筛查约可挽救120例T2DM患者免于因DR导致的失明；单因素敏感性分析结果显示，对ICER影响最大的健康效益值参数和成本参数分别为失明患者的健康效益值和并发糖尿病视黄斑水肿（DME）患者的年治疗成本；概率敏感性分析结果显示，深圳市居民对DR社区筛查具有良好的支付意愿，且DR筛查在支付意愿阈值>10 478.28元/QALY的情况下可带来远大于采取不筛查策略时的收益。

结论

深圳市DR社区筛查策略具有良好的经济学效益，可在深圳市基层医疗机构进行推广。

糖尿病视网膜病变（DR）  /  2型糖尿病（T2DM）  /  社区筛查策略  /  卫生经济学评价  /  深圳市
Objective

To conduct a health economic evaluation of a community-based screening strategy for diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM) in Shenzhen, Guangdong Province, and to provide evidence for implementation of this screening strategy in primary healthcare facilities in the city.

Methods

Community-based DR screening was conducted from August to December 2021 among 1200 T2DM patients recruited from 10 administrative districts in Shenzhen using a two-stage random sampling approach. A Markov model was constructed from a health care services perspective to conduct a cost-effectiveness analysis of the community-based DR screening strategy, with community-based DR screening as the intervention strategy and no screening as the control. Costs, effect sizes, and incremental cost-effectiveness ratios (ICERs) were estimated. Univariate and probabilistic sensitivity analyses were performed to assess the robustness of the results.

Results

Of the 1 097 participants finally included in the analysis, 266 (24.3%) were diagnosed with DR. Through 20 simulated cycles of systematic screening, the control (no screening) and intervention (screening) groups incurred costs of Chinese Yuan (CNY) 38 882.05 and CNY 41 920.75, respectively, and gained 17.13 and 17.42 quality adjusted life years (QALYs), respectively. The incremental cost-effectiveness ratio (ICER) was CNY 10 478.28/QALY. The net monetary benefits were CNY 218 071.06 and CNY 219 409.58 for the control and intervention groups, respectively, with a benefit-cost ratio of 5.23 for the screening strategy (indicating an indirect return of CNY 5.23 per CNY 1 invested). After 20 simulation cycles, the blindness rate was 21.0% (no screening) versus 10.1% (screening), with screening preventing approximately 120 cases of DR-related blindness in T2DM patients. Sensitivity analyses identified the health utility of blind patients and the annual cost of DME treatment as the most influential parameters. Probabilistic analysis showed good willingness-to-pay (WTP) among T2DM patients in Shenzhen, with screening being cost-effective at WTP thresholds > CNY 10 478.28/QALY.

Conclusions

The results demonstrate that the community-based DR screening strategy for T2DM patients in Shenzhen City is cost-effective and can be promoted in primary healthcare facilities in similar urban settings.

diabetic retinopathy  /  type 2 diabetes mellitus  /  community-based screening strategy  /  health economics evaluation  /  Shenzhen city
张紫阳, 张崇威, 林雅粒, 虞静雯, 吴肖冰. 深圳市2型糖尿病患者糖尿病视网膜病变社区筛查策略卫生经济学评价. 中国公共卫生, 2025 , 41 (5) : 557 -561 . DOI: 10.11847/zgggws1145119
Ziyang ZHANG, Chongwei ZHANG, Yali LIN, Jingwen YU, Xiaobing WU. Health economic evaluation of community-based diabetic retinopathy screening among type 2 diabetes mellitus patients in Shenzhen, China: a Markov model simulation study[J]. Chinese Journal of Public Health, 2025 , 41 (5) : 557 -561 . DOI: 10.11847/zgggws1145119
正文
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糖尿病视网膜病变（diabetic retinopathy, DR）是糖尿病最常见的微血管并发症之一，也是致使糖尿病患者视力减弱、失明的主要原因[1]，2020年中国成年人DR患病率约为16.3%[2]。《国家基层糖尿病防治管理指南（2022）》[3]提出，建议有条件的基层医疗卫生机构为2型糖尿病（type 2 diabetes mellitus，T2DM）患者每年至少进行1次视网膜病变筛查，包括视力检查和眼底检查等。然而，目前我国基层医疗卫生机构普遍存在人才紧缺、配置欠缺或分配不均等问题[4]，给DR筛查的推广带来了一定限制，同时较少有研究从卫生经济学角度对DR社区筛查的可行性进行分析。因此，本研究于2021年8—12月采用两阶段随机抽样方法在深圳市10个行政区中抽取1 200例T2DM患者进行DR社区筛查，并以DR社区筛查为研究策略、不筛查为对照策略，从医疗卫生服务角度构建Markov模型对深圳市DR社区筛查策略进行成本效益分析，旨在为基层医疗卫生机构DR筛查的推广提供参考依据。结果报告如下。
1　对象与方法
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1.1　对象
采用两阶段随机抽样方法，在深圳市10个行政区（含新区）中，每个行政区采用与糖尿病患者管理规模成比例的抽样方法随机抽取20个服务调查点，采用随机抽样方法在每个服务调查点分别抽取60例在深圳市社区健康服务机构建档并接受T2DM健康管理服务的≥18岁T2DM患者作为研究对象进行DR社区筛查，排除有眼外伤和青光眼等其他眼病、正在接受或接受过视网膜炎凝治疗以及患有高血压伴脑出血、自身免疫性疾病或肿瘤等其他影响研究的疾病者。本研究经深圳市慢性病防治中心伦理委员会审查批准（批号SZCCC-202300401PJ），且所有调查对象均签署了知情同意书。本次应调查1 200例T2DM患者，实际调查1 097例，有效应答率为91.42%。
1.2　方法
由经过统一培训的社区健康服务机构医护人员采用深圳市慢性病防治中心自行编制的调查问卷收集研究对象的一般信息，内容包括人口学信息、社会经济状况、生活方式行为和DR社区筛查的成本（筛查、宣传、培训、督导及管理等相关费用）等；由经过统一培训的专业技术人员采用SW-8800免散瞳照相机（天津市索维电子技术有限公司）对接受筛查的T2DM患者拍摄≥2张以黄斑及视乳头为中心的45°广角眼底后极部彩色照片，并将其连同患者资料上传至云端，采用2002年悉尼国际眼科的制定标准[5]，由专业的眼科医生进行结果的判读并返回相关诊断意见。
1.3　统计分析（图1、表1）
应用TreeAge Pro 2011进行基于决策树Markov模型的卫生经济学评价和敏感度分析。模型将DR的疾病自然史分为无DR、轻度非增殖性糖尿病视网膜病变（mild non-proliferative diabetic retinopathy, NPDR） 、中度非增殖性糖尿病视网膜病变（moderate mild non-proliferative diabetic retinopathy, mNPDR）、重度非增殖性糖尿病视网膜病变（sever mild non-proliferative diabetic retinopathy, sNPDR）、增殖期糖尿病视网膜病变（proliferative diabetic retinopathy, PDR）和失明6个阶段，其中糖尿病视黄斑水肿（macular edema in diabetes, DME）可独立发生，也可伴发于任何1个DR疾病状态。研究表明患者的生命质量与视力情况密切相关[6]，因此本研究中以失明作为研究的终点结局。由于本研究mNPDR和sNPDR患者转诊制度相同，因此其合并为一个状态为复杂非增殖性糖尿病视网膜病变（complex non-proliferative diabetic retinopathy, cNPDR）。在每一周期内，允许的健康状态之间的过渡为：无DR可能保持或进展为mNPDR，mNPDR可能保持或进展为cNPDR，cNPDR可能保持或进展为PDR，PDR可能保持或进展为失明，上述任一状态均有可能并发DME，DME可能保持或继续进展为失明（见图1）。用于构建Markov决策模型所需要的效用值和转移概率来源于文献检索的结果，对于缺少95%CI的参数则采用（±25%）作为相应参数的敏感度分析范围[7]；成本来源于现场调查及查阅深圳市基本医疗服务价格项目目录，成本参数采用（±50%）作为相应成本参数的敏感度分析范围（见表1）。2021深圳市居民人均期望寿命达到83.73岁，以本研究中的人群模拟队列进行研究，筛查起始年龄设定为队列人群平均年龄为（57.84±10.45）岁，以1年作为1个筛查周期，共设置20个循环周期[8]。
2　结　果
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2.1　初始概率
本研究最终对深圳市1 097例T2DM患者进行DR社区筛查，其中患DR者266例，DR患病率为24.3%；266例DR者中，NPDR者186例，cNPDR者73例，PDR者7例，据此计算各DR状态占总筛查例数的比例作为模型的初始概率：无DR为0.758，NPDR为0.212，cNPDR为0.024，PDR为0.006，DME和失明的初始概率均为0。
2.2　深圳市T2DM患者DR社区筛查成本效益分析
通过模拟20个周期进行系统性筛查，不筛查组和筛查组的成本分别为38 882.05和41 920.75元，可分别获得17.13和17.42个质量调整生命年（quality adjusted life year，QALY），增量成本效果比（incremental cost effective ratio，ICER ）值为10 478.28元；对筛查策略下的收益及成本进行比较，不筛查组和筛查组的净效益（net-monetary benefit，NMB）分别为218 071.06和219 409.58元，DR社区筛查策略的效益成本比（benefit-cost ratio，BCR）为5.23，在本筛查策略下每投入1元成本可获益5.23元的间接货币收益；不筛查组和筛查组经过20个周期模拟后失明例数的比例分别为21.0%和10.1%，本次DR社区筛查约可挽救120例T2DM患者免于因DR导致的失明。
2.3　敏感性分析
2.3.1　单因素敏感性分析（图2）
在卫生系统角度下，对该模型的健康效益值、诊断服务各项成本绘制飓风图进行单因素敏感性分析。结果显示，对ICER影响最大的健康效益值参数为失明患者的健康效益值，其他依次为并发DME患者的健康效益值、并发PDR患者的健康效益值、并发mNPDR患者的健康效益值、T2DM未并发DR患者的健康效益值、并发sNPDR患者的健康效益值和DR引起失明患者的健康效益值；对ICER影响最大的成本参数为并发DME患者的年治疗成本，其他依次为T2DM患者的年治疗成本、DR的筛查成本、T2DM合并DR患者的年治疗成本、视网膜光凝术的治疗成本、印刷宣传及培训的成本、对T2DM患者进行督导及管理的成本和行玻璃体切除术的成本。本研究的飓风图具有良好的对称性，表明该模型的卫生经济学评价结果具有稳健性。
2.3.2　概率敏感性分析
概率敏感性分析结果显示，每年系统性筛查的ICER为10 478.28元/QALY，远低于2021年深圳市3倍人均GDP，即466 689元/QALY的支付意愿阈值[17]，深圳市居民对DR社区筛查具有良好的支付意愿，且DR筛查在支付意愿阈值>10 478.28元/QALY的情况下可带来远大于采取不筛查策略时的收益。
3　讨　论
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本研究基于Markov模型模拟了DR在深圳市社区筛查或不筛查干预情况下的发生情况，并对其进行了卫生经济学评价。结果显示，对深圳市T2DM患者每年进行DR社区筛查具有较好的成本效益，与国内外研究[17–18]结果均一致。本研究中ICER是指社区筛查策略相对于不筛查的成本增量与效果增量的比值，它衡量了每增加1个QALY所需的成本，ICER值远低于2021年深圳市3倍人均GDP，即466 689元/QALY的支付意愿阈值[17]，可认为具有成本效益。DR社区筛查策略下的NMB高于不筛查，提示DR社区筛查具有较好的经济效益。在筛查策略下BCR值为5.23，即在本筛查策略下每投入1元成本可获益5.23元的间接货币收益，亦提示本筛查策略具有较好的成本效益。
对于糖尿病视网膜病变的早、中期患者，其临床症状不明显，而患者进行并发症筛查的频率受T2DM患者自我感知风险影响，当患者无明显自觉症状时，往往觉得麻烦或者因忌医选择不就医或延缓就医，导致DR进一步发展恶化[19–20]，因此社区筛查显得尤为重要。一项研究表明，糖化血红蛋白≥7%的T2DM患者患DR的风险为糖化血红蛋白<7%T2DM患者的2.45倍，同时DR患病风险亦与患者的病程和生活方式存在相关性[21]，因此在卫生资源有限的情况下，建议根据T2DM患者的特征分层制定个性化的DR筛查策略，在保证DR筛查效果的同时进一步优化筛查成本效益。
本研究通过单因素敏感性分析和概率敏感性分析从2个角度评估了研究的不确定性，结果显示本研究结果具有较好的稳健性。其中，“失明患者的健康效益值”在本次敏感性分析结果中对ICER的影响最大，因此应积极对DR患者开展系统性筛查，将防治其因DR导致的失明作为工作重点。有研究表明，慢性病共病患者的支付意愿与药品可及性和自付费用均具有相关性[22]，因此深圳市基层医疗机构应进一步改善医疗卫生服务的可及性，促进社区健康的服务工作质量，完善医疗保障制度，减轻患者的医疗经济负担。
综上所述，深圳市DR社区筛查策略具有良好的经济学效益，可在深圳市基层医疗机构进行推广。虽然《国家基层糖尿病防治管理指南（2022）》[3]已明确有条件的社区卫生服务中心应配置免散瞳眼底照相机用于DR社区筛查，但深圳市社区健康服务机构的配置比例较低，因此应逐步提高基层医疗机构眼病筛查设备的配置，从而促进DR社区筛查的覆盖范围，以便对并发眼病的T2DM患者做到早发现、早治疗、定期复查。但本研究也存在一定的局限性：首先，本研究根据《国家基层糖尿病防治管理指南（2022）》[3]只能得出每年的社区筛查策略优于不筛查策略，而不能确定达到最优ICER时的筛查年限，有待于在今后的研究中进一步探讨；其次，糖尿病患者并发症的发生相对复杂，DR的筛查、诊疗以及转诊机制都较为个体化，深圳市目前缺少DR各级状态长时间转化率等相关数据，对研究结果可能带来一定影响，但本研究在设置Markov模型结构时考虑了多种转移途径来细化模型，在一定程度上降低了个体差异对模型结果带来的影响。

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doi: 10.11847/zgggws1145119
  • 接收时间：2024-06-04
  • 首发时间：2026-10-25
  • 出版时间：2025-05-10
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  • 收稿日期：2024-06-04
  • 修回日期：2024-12-23
  • 录用日期：2025-04-12
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    深圳市慢性病防治中心，深圳 518000

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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