涙道閉塞に対する涙道内腔再建術と涙囊鼻腔吻合術の費用対効果比較

Cost-effectiveness of endoluminal lacrimal duct recanalization and dacryocystorhinostomy for nasolacrimal duct obstruction

要約　目的：涙道閉塞に対する涙道内腔再建術（ELDR）および涙囊鼻腔吻合術（DCR）について，臨床効果と診療報酬に基づく費用面から両術式の費用対効果を比較検討する。

対象と方法：2023年に当院でELDRまたはDCRを施行した涙道閉塞症例69例を対象とした。観察期間中に涙道閉塞以外の治療を行った例，および術後合併症治療を要した例は除外した。費用はレセプトデータより観察期間内の総診療報酬点数から算出，効果は成功率（通水陽性＋症状解消）と定義し，費用効果比（CER）および増分費用効果比（ICER）を算出した。

結果：単眼例の平均費用はELDR 91,900円，DCR 401,910円であった。成功率はELDR 78％，DCR 95％であり，ICERは1,821,353円/成功であった。両眼例においても同様の傾向を示し，ELDRが費用対効率の面で優位であった。ELDRの成功率が約20％を下回るとDCRのCERが逆転した。

結論：診療報酬に基づく比較により，ELDRはDCRより短期的には費用対効果が高く，一定の成功率を維持できる場合には有用な術式であると考えられた。

Abstract　Purpose：The aim in this study was to compare the cost-effectiveness of endoluminal lacrimal duct recanalization（ELDR） and endonasal dacryocystorhinostomy（DCR） in treating nasolacrimal duct obstruction based on clinical outcomes and medical reimbursement costs.

Subjects and methods：Sixty-nine cases of acquired nasolacrimal duct obstruction who underwent ELDR or DCR at our clinic in 2023 were retrospectively reviewed. Cases requiring treatment beyond those than nasolacrimal obstruction or postoperative complications were excluded. The costs were calculated at total medical reimbursement points during the observation period, and effectiveness was defined as surgical success（patent irrigation with symptom resolution）. The cost-effectiveness ratio（CER） and incremental cost-effectiveness ratio（ICER） were calculated.

Results：The mean cost per eye was \91,900 and \401,910 for ELDR and DCR, respectively. The success rates were 78％ and 95％ for ELDR and DCR, respectively yielding an ICER of \1,821,353 per additional success. Similar trends were observed in bilateral cases, for which ELDR was more cost efficient. Sensitivity analysis indicated that the CER of DCR was higher than that of ELDR when the ELDR success rate dropped below approximately 20％.

Conclusion：ELDR is more cost-effective than DCR in the short term according to the analysis of medical reimbursement data and clinical outcomes. ELDR may serve as a useful and economically efficient alternative procedure to DCR for nasolacrimal duct obstruction above a certain level of surgical success.