harmaecono-药物治疗疼痛的经济因素考虑.ppt

2020 3 22 EconomicConsiderationsinthePharmacologicManagementofPain 药物治疗疼痛中的经济因素考虑 LiuZhanXian JanssenPharmaceuticalLtd 2020 3 22 GeneralIntroductionofPain 疼痛概论 Definition 疼痛的定义 Physicalpainisacommon subjectiveandcomplicatedprocessthatisinitiatedbyanunpleasantsensoryexperience Itoccursviaseveralmechanismsthatmayresultinimmobility deconditioningandemotionalreactions 躯体疼痛是由于不愉快的感觉经验引起的一种常见的 主观的和复杂的过程 它是通过可引起行动受限 状态异常和情绪反应的一系列机制而发生的 2020 3 22 Epidemiology 流行病学资料 75millionpeopleinU S havesomeformofpersistentorrecurrentpain andpainisthemostcommonsymptomforwhichpatientsseekmedicalassistance 在美国有超过七千五百万人患有不同程度的持续性或反复发生的疼痛 疼痛已成为患者求医的最常见的症状 在中国 130万癌症死亡人群中 60 以上忍受着中到重度疼痛 GeneralIntroductionofPain 疼痛概论 CaudillM HolmanG TurkD PatientCare 1996 154 FoleyK CecilTextbookofMedicine Philadelphia 1992 97 2020 3 22 GreatestChallenge 伟大的挑战 Thegreatesthealthcarechallengeforthenextdecadeistomakethebestuseoflimitedavailableresourcestoattainthehighestqualityofhealthcareforthelowestcost Aspharmacoeconomicdatabecomeincreasinglyavailable theiruseincost effectivepainmanagementandinallhealthcaredecisions willplayamajorrole Thepharmacistisuniquelypoisedtoadapttothisshiftingparadigm 在下一个十年中 对健康领域里的最大的挑战是充分利用可得到的有限资源 利用最低的花费来得到最高的健康质量 由于药物经济学资料的增加 在疼痛控制健康项目决策中 其花费和结果的研究将起主要作用 药剂师们在适应这场变更中起着独一无二的平衡作用 GeneralIntroductionofPain 疼痛概论 MichaelRigas EconomicConsiderationsinthePharmacologicManagementofPain P Ts1997 454 2020 3 22 ClassificationofPain 疼痛的分类 TemporalClassification 时间分类 AcutePainChronicPainusuallydefinedasthatlasting6monthsorlongerthetiming localizationandcharacterofthepainareoftenmorevague 疼痛的时间 部位和性质经常是含糊的 Theremaybeindicationsofsleepdisturbances lossofappetite decreasedlibido weightlossanddepression 经常伴有睡眠干扰 食欲不振 性欲下降 体重降低及抑郁 PhysiologicClassification 生理学分类 Somatic Visceral Neuropathic 躯体 内脏 神经性 GeneralIntroductionofPain 疼痛概论 2020 3 22 PainManagementPrinciples 疼痛控制原则 AcutePainpatienteducationonpostoperativepaintheneedforregularlyscheduledanalgesicsasopposedtoas neededanalgesicsforthefirst24hoursofmoreaftersurgerytheneedforfrequentassessmentandreassessmentofpainbynursingpersonneltheneedforconsistentuseofatoolforpatientself assessmentofpainthepossibilityofpreemptiveanalgesicstrategiesforsurgicalpatientsthespecificanalgesicstrategiesofferedtopatients GeneralIntroductionofPain 疼痛概论 guidelinesandqualityassurancestandardsfromtheAgencyforHealthCarePolicyandResearch AHCPR 2020 3 22 ChronicPainWHOanalgesicladder WHO阶梯疗法 Nonopioid AdjuvantWeakopioid Nonopioid AdjuvantStrongopioid Nonopioid Adjuvantcanprovidesatisfactorypainreliefto70 90 ofthispatientpopulation 可使70 90 的中到重度癌痛患者得到满意地缓解 Durogesicisthenoveladministrationwayinchronicpainrelief 多瑞吉的出现创新了慢性痛控制领域里的给药途径 GeneralIntroductionofPain 疼痛概论 WHOcitedinPortenoyR Issuesintheeconomicanalysisoftherapiesforcancerpain Oncology 1995 9 11 S71 2020 3 22 PharmacologicTherapiesofPain 疼痛的药物治疗 Theappropriateandsuccessfulmanagementofpainentailsselectionoftherightanalgesic administeredintherightway dosageandontherightschedulesoastomaximizepainreliefandminimizeadverseeffects 适当和成功的疼痛控制必需选择正确的止痛药物 正确的途径和剂量以正确的时间间隔给药 从而达到能最大缓解疼痛的同时将副作用降到最小 Estimates InturrisiC Managementofcancerpain pharmacologyandprinciplesofmanagement Cancer 1989 63 2308 2020 3 22 NonnarcoticAnalgesics 非麻醉性镇痛药 Aspirin AcetaminophenandNSAIDs 阿斯匹林 对乙酰氨基酚及非甾体抗炎药 firstlineagentsforthetreatmentofmild to moderatepain 是轻到中度疼痛的一线用药 ceilingeffect 天花板效应 anincreaseinthedosagebeyondtherecommendedmaximumdosenotresultinanincreaseinanalgesia andpotentiallyincreasessideeffectsnotsuitableuseforchronic evolvingpain 不适合用于慢性 进展性疼痛 PharmacologicTherapiesofPain 疼痛的药物治疗 AshbyM etal Descriptionofamechanisticapproachtopainmanagementinadvancedcancer Preliminaryreport Pain 1992 51 153 2020 3 22 NarcoticAnalgesics 麻醉性镇痛药 Narcoticmedicationshouldbeadministeredonaregularbasissoastomaintaintheplasmalevelofthedrugabovetheminimaleffectiveconcentrationforpainrelief Itisnotrecommendedthatpatientswithchronicpaintakenarcoticsonanas requiredbasis becausewaitinguntilthepainordistressbecomesmoreseveremayactuallyexacerbatethepain 麻醉性镇痛药物的使用应按时给药 而不是按需给药 这样才能使药物的血浆浓度维持在最低有效的疼痛缓解浓度之上 同时 按需给药可使疼痛更加恶化 PharmacologicTherapiesofPain 疼痛的药物治疗 RalphsJetal Opiatereductioninchronicpainpatients Pain 1994 56 279 2020 3 22 Agonistcommonlyusedinthemanagementofchronicpain suchascancerpain 激动剂通常用于慢性疼痛的治疗 如癌痛 Agonist antagonistoftenusedinacutepostoperativepainmanagement butareoflimiteduseinchronicpain 激动剂 拮抗剂通常用于急性手术后疼痛控制上 而不用于慢性疼痛的治疗 PharmacologicTherapiesofPain 疼痛的药物治疗 2020 3 22 AdverseeffectsofnarcoticsDespitetheprovenefficacyofnarcoticsinthemanagementofpain thedevelopmentofadverseeffectsisalsotypicalwiththeseagents 尽管麻醉性镇痛药在疼痛控制上有确切疗效 但这些药物的不良反应反应也是很典型的 opioidsideeffectsdependonanumberoffactorsthatinclude patientage extentofdiseaseandorgandysfunction concurrentadministrationofcertaindrugs prioropioidexposureandtherouteofdrugadministration 阿片类药物不良反应的影响因素有 年龄 疾病和器官功能受损程度 从前阿片类药物使用状况和给药途径 PharmacologicTherapiesofPain 疼痛的药物治疗 InturrisiC Managementofcancerpain pharmacologyandprinciplesofmanagement Cancer 1989 63 2308 2020 3 22 Commonadverseeffectssedation nausea vomiting constipation respiratorydepressionandtolerance 镇静 恶心 呕吐 便秘 呼吸抑制及耐药性 Adverseeffectsevaluationisoneoftheimportantpartsofnarcoticpharmacoeconomicevaluation 对不良反应的评价是麻醉性镇痛药物进行药物经济学评价的重要部分之一 PharmacologicTherapiesofPain 疼痛的药物治疗 2020 3 22 AdjunctiveTherapies 辅助性治疗 anticonvulsants antidepressant stimulants antihistamine phenothiazine steroids miscellaneous anxiolytics 抗惊厥药 抗抑郁药 兴奋剂 抗组胺药 酚噻嗪 类固醇类 杂环类 抗焦虑药 mostoftheseagentsareveryinexpensiveandtheycanbeverycost effectivewhenappropriatelyco prescribedtohelpcontrolpain 大部分这类药物非常便宜 在疼痛控制上的适当应用 可有很好的 效 价 比 PharmacologicTherapiesofPain 疼痛的药物治疗 2020 3 22 VariousRoutesofAdministration AdvantagesandDisadvantages 不同给药途径的优缺点比较 2020 3 22 ProprietaryDrugsVersusGenerics 专利药物与仿制药物 Theobjectiveofmakingformulariesistomaximizecost effectivenessbyexcludingorlimitingexpensivemedicationsaslongasthequalityofcareisnotcompromised 制定药物目录的目的是在提供的健康服务质量不受损害的情况下通过不用或限制使用昂贵药物以使 效 价 比达到最大 JohnsonJ etal Pharmacoeconomicanalysisinformularydecisions aninternationalperspective AmJHospPharm 1994 51 2593 2020 3 22 NonpharmacologicApproachestoPainManagement 非药物治疗方法 Factorstobeconsideredarewhethertheinterventioneffectivelymobilizesapatient reducestheneedforanursinghomeornursingathome preventshospitalization reducesideeffectsandoverallcost 对这些治疗的考虑在于其是否可明显增加病人的活动 降低对护理的需求 减少住院 降低不良反应和能降低总支出 PhysicalInterventions 物理疗法 BehavioralInterventions 行为疗法 PortenoyR etal Issuesintheeconomicanalysisoftherapiesforcancerpain Oncology 1995 9 11 S71 2020 3 22 EconomicIssuesintheManagementofPain 疼痛控制中的经济因素 Thecostofnotmanagingaswellasmanagingchronicpainarepotentiallyveryhigh Themorbideffectsofunrelievedpainonmoodandimmobilitycanresultinnumerousmedicalinterventions Pain relatedcomplications expensivediagnosticprocedures hospitalizationsforpaincontrolanddaysmissedfromworkcanbeextremelycostly 不控制疼痛和对慢性疼痛的控制的花费可能是很高的 疼痛不缓解在人的情绪和行动上的病态可导致相当多的医疗问题出现 与疼痛有关的并发症 昂贵的诊断手段 为控制疼痛而住院治疗以及为此耽误工作的代价都是非常高的 2020 3 22 PrimaryIssues 主要因素 thecostofpharmacotherapy themostimportantanalgesicapproachforcancerpain 药物治疗费用 对于癌痛而言是最重要的止痛方法 Incorporatingpharmacoeconomicdataintotheformularydecision makingprocess helpsinselectingmedicationsthataresafe effectiveandcost efficient 将药物经济学数据放入药物目录的评审中 这将有助于选择出既安全有效又 效 价 比合适的药物 Toperformacomprehensiveevaluationofanexistingorproposedpharmaceuticalservice 对现有的或提议中的药事服务进行深入的评估是很有必要的 EconomicIssuesintheManagementofPain 疼痛控制中的经济因素 2020 3 22 OtherIssues 其它因素 thedifferencesintreatmentsettings 治疗方案的差异 theneedtojustifyservices 服务需求的调整 reimbursementbiases 报销目录的倾斜 thepotentialforconflictofinterest 潜在的公私利益冲突 EconomicIssuesintheManagementofPain 疼痛控制中的经济因素 2020 3 22 Pharmacoeconomics MethodsandGuidelines 药物经济学的方法及指导原则 MethodsCost minimizationAnalysisOutcomesareconsideredtobeequalandcompareonlytheimputesorcostsofeachalternativewhenefficacyandsideeffectsaresimilarCost benefitAnalysismeasuresoutcomesindollars Theoutcomemaybeexpressedinratioofbenefittocost ortheratioofthedifference netcosttobenefit ornetcost benefitminuscost Cost effectivenessAnalysismeasuresoutcomesinnonmonetaryunits e g thecostperunitofsuccessoreffect thecostperhourofreducednursingcaretimeorpermmHgchangeinBPforantihypertensivetherapy 2020 3 22 Pharmacoeconomics MethodsandGuidelines 药物经济学的方法及指导原则 Cost utilityAnalysisOutcomesexpressedinnonmonetaryunitsareadjustedforhealth relatedqualityoflife Cost of illnessAnalysisattemptstoidentifyalldirectandindirectcostsoftreatingacertaindiseaseorillness 2020 3 22 BasicPrinciplestoGuidethePharmaco economicProcess 指导原则 DefinetheproblemDeterminethestudy sperspectiveDeterminethealternativesan