Decision analysis as an aid to determining the management of early low rectal cancer for the individual patient.
(17/2098)
PURPOSE: Because there are no data available from randomized controlled trials (RCT), a decision analysis was performed to aid in the decision of which option, a local excision with or without radiotherapy or an abdominal perineal resection (APR), should be offered to medically fit patients with early (suspected T1/T2) low (< 5 cm) rectal cancer. METHODS: All clinically relevant outcomes, including complications of surgery and radiotherapy, cure, salvageability after local recurrence, distant disease, and death, were modeled for both options. The probabilities of complications and outcomes after radiotherapy and/or local excision were derived from weighted averages of results from studies conducted between 1969 and 1997. The probabilities for the APR option were extracted from relevant RCTs. Long- and short-term patient-centered utilities for each complication and outcome were extracted from the literature and from expert opinion. RESULTS: The expected utility of local excision (EU = 0.81) for the base case was higher than the expected utility for APR (EU = 0.78). Although the result was sensitive to all variables, local excision was always favored over APR within the plausible ranges of the variables taken one, two, or three at a time. The model illustrated the tension between the patient's perception of a colostomy and the higher recurrence rates with local excision. CONCLUSION: The results of this decision analysis suggest that local therapy for early low rectal cancer is the preferred method of treatment. However, there must be careful preoperative assessment, patient selection, and consideration of patient concerns. In addition, decision analysis may be useful in providing patient information and assisting in decision making. (+info)
Economic analysis of step-wise treatment of gastro-oesophageal reflux disease.
(18/2098)
BACKGROUND: To expose patients with gastro-oesophageal reflux disease (GERD) to the least amount of medication and to reduce health expenditures, it is recommended that their treatment is started with a small dose of an antisecretory or prokinetic medication. If patients fail to respond, the dose is increased in several consecutive steps or the initial regimen is changed to a more potent medication until the patients become asymptomatic. Although such treatment strategy is widely recommended, its impact on health expenditures has not been evaluated. METHODS: The economic analysis compares the medication costs of competing medical treatment strategies, using two different sets of cost data. Medication costs are estimated from the average wholesale prices (AWP) and from the lowest discount prices charged to governmental health institutions. A decision tree is used to model the step-wise treatment of GERD. In a Monte Carlo simulation, all transition probabilities built into the model are varied over a wide range. A threshold analysis evaluates the relationship between the cost of an individual medication and its therapeutic success rate. RESULTS: In a governmental health care system, a step-wise strategy saves on average $916 per patient every 5 years (range: $443-$1628) in comparison with a strategy utilizing only the most potent medication. In a cost environment relying on AWP, the average savings amount to $256 (-$206 to +$1561). The smaller the cost difference between two consecutive treatment steps, the longer one needs to follow the patients to reap the benefit of the small cost difference. However, even a small cost difference can turn into tangible cost savings, if a large enough fraction of GERD patients responds to the initial step of a less potent but also less expensive medication. CONCLUSIONS: The economic analysis suggests that a step-wise utilization of increasingly more potent and more expensive medications to treat GERD would result in appreciable cost savings. (+info)
Decision aids for patients facing health treatment or screening decisions: systematic review.
(19/2098)
OBJECTIVE: To conduct a systematic review of randomised trials of patient decision aids in improving decision making and outcomes. DESIGN: We included randomised trials of interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Two reviewers independently screened and extracted data on several evaluation criteria. Results were pooled by using weighted mean differences and relative risks. RESULTS: 17 studies met the inclusion criteria. Compared with the controls, decision aids produced higher knowledge scores (weighted mean difference=19/100, 95% confidence interval 14 to 25); lower decisional conflict scores (weighted mean difference=-0.3/5, -0.4 to -0.1); more active patient participation in decision making (relative risk = 2.27, 95% confidence interval 1. 3 to 4); and no differences in anxiety, satisfaction with decisions (weighted mean difference=0.6/100, -3 to 4), or satisfaction with the decision making process (2/100,-3 to 7). Decision aids had a variable effect on decisions. When complex decision aids were compared with simpler versions, they were better at reducing decisional conflict, improved knowledge marginally, but did not affect satisfaction. CONCLUSIONS: Decision aids improve knowledge, reduce decisional conflict, and stimulate patients to be more active in decision making without increasing their anxiety. Decision aids have little effect on satisfaction and a variable effect on decisions. The effects on outcomes of decisions (persistence with choice, quality of life) remain uncertain. (+info)
Decision analysis in nuclear medicine.
(20/2098)
This review focuses primarily on the methodology involved in properly reviewing the literature for performing a meta-analysis and on methods for performing a formal decision analysis using decision trees. Issues related to performing a detailed metaanalysis with consideration of particular issues, including publication bias, verification bias and patient spectrum, are addressed. The importance of collecting conventional measures of test performance (e.g., sensitivity and specificity) and of changes in patient management to model the cost-effectiveness of a management algorithm is detailed. With greater utilization of the techniques discussed in this review, nuclear medicine researchers should be well prepared to compete for the limited resources available in the current health care environment. Furthermore, nuclear medicine physicians will be better prepared to best serve their patients by using only those studies with a proven role in improving patient management. (+info)
Personalized health care and business success: can informatics bring us to the promised land?
(21/2098)
Perrow's models of organizational technologies provide a framework for analyzing clinical work processes and identifying the management structures and informatics tools to support each model. From this perspective, health care is a mixed model in which knowledge workers require flexible management and a variety of informatics tools. A Venn diagram representing the content of clinical decisions shows that uncertainties in the components of clinical decisions largely determine which type of clinical work process is in play at a given moment. By reducing uncertainties in clinical decisions, informatics tools can support the appropriate implementation of knowledge and free clinicians to use their creativity where patients require new or unique interventions. Outside health care, information technologies have made possible breakthrough strategies for business success that would otherwise have been impossible. Can health informatics work similar magic and help health care agencies fulfill their social mission while establishing sound business practices? One way to do this would be through personalized health care. Extensive data collected from patients could be aggregated and analyzed to support better decisions for the care of individual patients as well as provide projections of the need for health services for strategic and tactical planning. By making excellent care for each patient possible, reducing the "inventory" of little-needed services, and targeting resources to population needs, informatics can offer a route to the "promised land" of adequate resources and high-quality care. (+info)
Use of meta-analytic results to facilitate shared decision making.
(22/2098)
OBJECTIVES: Describe and evaluate an Internet-based approach to patient decision support using mathematical models that predict the probability of successful treatment on the basis of meta-analytic summaries of the mean and standard deviation of symptom response. DESIGN: An Internet-based decision support tool was developed to help patients with benign prostatic hypertrophy (BPH) determine whether they wanted to use alpha blockers. The Internet site incorporates a meta-analytic model of the results of randomized trials of the alpha blocker terazosin. The site describes alternative treatments for BPH and potential adverse effects of alpha blockers. The site then measures patients' current symptoms and desired level of symptom reduction. In response, the site computes and displays the probability of a patient's achieving his objective by means of terazosin or placebo treatment. SETTING: Self-identified BPH patients accessing the site over the Internet. MAIN OUTCOME MEASURES: Patients' perceptions of the usefulness of information. RESULTS: Over a three-month period, 191 patients who were over 50 years of age and who reported that they have BPH used the decision support tool. Respondents had a mean American Urological Association (AUA) score of 18.8 and a desired drop in symptoms of 10.1 AUA points. Patients had a 40 percent chance of achieving treatment goals with terazosin and a 20 percent chance with placebo. Patients found the information useful (93 percent), and most (71 percent) believed this type of information should be discussed before prescribing medications. CONCLUSIONS: Interactive meta-analytic summary models of the effects of pharmacologic treatments can help patients determine whether a treatment offers sufficient benefits to offset its risks. (+info)
Validation of the Ottawa ankle rules in children.
(23/2098)
OBJECTIVE: To assess whether the Ottawa ankle rules can be used to accurately predict which children with ankle and midfoot injuries need radiography. METHODS: Prospective study with historical control group of all children aged 1-15 years presenting to Sheffield Children's Hospital accident and emergency department with blunt ankle and/or midfoot injuries during two five month periods before and after implementation of the Ottawa ankle rules. RESULTS: In the study group 432 out of 761 (56.76%) patients received radiography compared with 500 out of 782 (63.93%) in the control group. This was a statistically significant reduction in radiography rate of 7.2% (95% confidence interval 2.3% to 12.1%, p <0.01). The sensitivity of the Ottawa ankle rules was 98.3% and the specificity 46.9%. There was no increase in the number of missed fractures (one in each group). CONCLUSION: The Ottawa ankle rules can be applied in children to determine the need for radiography in ankle and midfoot injuries. Their implementation leads to a reduction in the radiography rate without leading to an increase in the number of missed fractures. (+info)
Functional anatomy of mitral regurgitation: accuracy and outcome implications of transesophageal echocardiography.
(24/2098)
OBJECTIVES: This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography. BACKGROUND: In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown. METHODS: In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined. RESULTS: Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease. CONCLUSIONS: Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR. (+info)