基于马尔可夫风险决策技术的社区脑卒中筛查与干预优化策略研究

Cerebrovascular disease is the first leading cause of death in China. The Stroke Screening, Prevention and Treatment Project (SSPP) had been started by the National Health and Family Planning Commission of the PRC in 2011. Residents will be systematically assessed based on the exposure of risk factors. Detected high risk population will receive a life-style intervention and treated if necessary. The cost-effectiveness of systematic stroke risk assessment and the following intervention can only be verified after an enough long-term follow-up. This study explores methods for finding optimal screening and intervention strategies by modelling the costs and benefits of screening and intervention programs through a simulation-based and a theoretical approach. This model simulation was used in cost effectiveness analysis of follow-up strategy for breast cancer patients and the optimization of breast cancer screening strategy in Chinese women. A design in which systematic stroke risk assessment embedded in general health check will be also tested by this model simulation. Data on performance of screening, intervention and treatment will be collected from a multi cross-sectional study. Information will be also extracted from literatures reporting the result of SSPP. State-transition Markov simulation model will be developed to simulate disease history of stroke, risk factor screening, awareness, intervention and control, treatment of stroke in a hypothetical, population based cohort of one million Chinese. Cox proportional regression will be used for the calculation of transition parameters in Markov micro simulation model. The cost effectiveness will be compared among strategy I (SSPP based on community) and strategy II (SSPP embedded in general health check). Monte-Carlo simulation will be used to identify the quality assurance targets for the performance of screening, intervention and treatment.

脑血管病已成为我国国民第一位死因。“脑卒中高危人群筛查和干预项目”是国家卫计委于2011年启动的重大公共卫生服务项目，旨在通过脑卒中危险因素系统风险评估，筛选出高危人群开展综合干预和随访管理。然而系统风险评估与干预相对于机会性筛查是否具有明确的临床和卫生经济学效果，尚需很长时间的随访与观察。本研究拟用马尔可夫决策技术，探索脑卒中高危人群筛查与防治优化策略。研究者所在课题组已应用马尔可夫微模拟模型，进行了乳腺癌术后随访策略和中国乳腺癌筛查优化策略研究。本研究将基于连续性横断面危险因素暴露水平调查数据、荟萃分析数据、脑卒中筛查与防治工程的短期效果数据，应用Cox比例风险评估模型估计状态转换函数，拟合马尔可夫决策过程，探索策略1-基于社区的脑卒中筛查与干预项目和策略2-将脑卒中高危人群筛查与干预纳入常规体检的卫生经济学效果，并通过蒙特卡洛随机模拟技术探寻确保策略成本有效的关键策略环节的质控目标。

课题组按照研究方案设计完成了计划书中的参数收集与估计、基于马尔可夫模型的脑卒中发病过程模型模拟、脑卒中高危人群筛查与干预策略成本效益分析以及蒙特卡洛随机模拟进行敏感性分析等全部内容，完成了申请书规定的研究目标，基于马尔可夫模型和多因素风险预测模型的脑卒中发病过程模拟、构建完成脑卒中高危人群筛查与干预策略的卫生经济学评价模型，评估预测了基于社区的脑卒中筛查与干预项目，将高危人群脑卒中筛查纳入常规体检项目的卫生经济学效果评价，并应用随机模拟技术，确定了脑卒中筛查与干预策略的过程质控指标的标准。在大的研究方向上，未做调整。作为本课题的支撑，增加了研究的内容，包括我国1990-2016年脑卒中疾病负担趋势分析；脑卒中发病率和死亡率的年龄-时期-队列模型分析；我国1990-2016年房颤疾病负担趋势分析；体检人群颈动脉粥样硬化现状分析及其影响因素；基于据China-PAR模型的颈动脉硬化人群10年心血管疾病风险分析等。. 本研究结果表明，我国脑卒中发病率处于上升趋势，且随着人口老龄化和生活方式的改变，还可能持续上升，脑卒中的预防工作迫在眉睫；将脑卒中高危人群筛查纳入常规体检的策略筛查，可以增加人群的生命年、质量调整寿命年以及减少脑卒中病例的发生；基于脑卒中筛查项目模型模拟结果显示，三年一次问卷+超声筛查策略应用于我国40岁以上人群更具有卫生经济学效果；房颤筛查模型结果显示，对65岁、75岁及以上人群开展房颤筛查预防脑卒中的卫生经济学效果较好。 . 综上研究结果，在我国当前的脑卒中疾病负担及经济条件下，针对脑卒中高危人群的筛查具有一定的指导价值，基于常规体检项目、脑卒中筛查项目和房颤单一危险因素筛查对于脑卒中的防治有一定的卫生经济学效果。