Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review

Decision analysis in cardiac surgery: a scoping review and methodological primer

OBJECTIVES

Randomized controlled trials are the gold standard for evidence generation in medicine but are limited by their real-world generalizability, resource needs, shorter follow-up durations and inability to be conducted for all clinical questions. Decision analysis (DA) models may simulate trials and observational studies by using existing data and evidence- and expert-informed assumptions and extend analyses over longer time horizons, different study populations and specific scenarios, helping to translate population outcomes to patient-specific clinical and economic outcomes. Here, we present a scoping review and methodological primer on DA for cardiac surgery research.

METHODS

A scoping review was performed using the PubMed/MEDLINE, EMBASE and Web of Science databases for cardiac surgery DA studies published until December 2021. Articles were summarized descriptively to quantify trends and ascertain methodological consistency.

RESULTS

A total of 184 articles were identified, among which Markov models (N = 92, 50.0%) were the most commonly used models. The most common outcomes were costs (N = 107, 58.2%), quality-adjusted life-years (N = 96, 52.2%) and incremental cost-effectiveness ratios (N = 89, 48.4%). Most (N = 165, 89.7%) articles applied sensitivity analyses, most frequently in the form of deterministic sensitivity analyses (N = 128, 69.6%). Reporting of guidelines to inform the model development and/or reporting was present in 22.3% of articles.

CONCLUSION

DA methods are increasing but remain limited and highly variable in cardiac surgery. A methodological primer is presented and may provide researchers with the foundation to start with or improve DA, as well as provide readers and reviewers with the fundamental concepts to review DA studies.

Methodologic and Reporting Quality of Economic Evaluations in Hand and Wrist Surgery: A Systematic Review

BACKGROUND

Economic evaluations can inform decision-making; however, previous publications have identified poor quality of economic evaluations in surgical specialties.

METHODS

Study periods were from January 1, 2006, to April 20, 2020 (methodologic quality) and January 1, 2014, to April 20, 2020 (reporting quality). Primary outcomes were methodologic quality [Guidelines for Authors and Peer Reviewers of Economic Submissions to The BMJ (Drummond's checklist), 33 points; Quality of Health Economic Studies (QHES), 100 points; Consensus on Health Economic Criteria (CHEC), 19 points] and reporting quality (Consolidated Health Economic Evaluation Standards (CHEERS) statement, 24 points).

RESULTS

Forty-seven hand economic evaluations were included. Partial economic analyses (i.e., cost analysis) were the most common (n = 34; 72 percent). Average scores of full economic evaluations (i.e., cost-utility analysis and cost-effectiveness analysis) were: Drummond's checklist, 27.08 of 33 (82.05 percent); QHES, 79.76 of 100 (79.76 percent); CHEC, 15.54 of 19 (81.78 percent); and CHEERS, 20.25 of 24 (84.38 percent). Cost utility analyses had the highest methodologic and reporting quality scores: Drummond's checklist, 28.89 of 35 (82.54 percent); QHES, 86.56 of 100 (86.56 percent); CHEC, 16.78 of 19 (88.30 percent); and CHEERS, 20.8 of 24 (86.67 percent). The association (multiple R) between CHEC and CHEERS was strongest: CHEC, 0.953; Drummond's checklist, 0.907; and QHES, 0.909.

CONCLUSIONS

Partial economic evaluations in hand surgery are prevalent but not very useful. The Consensus on Health Economic Criteria and Consolidated Health Economic Evaluation Standards should be used in tandem when undertaking and evaluating economic evaluation in hand surgery.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

BACKGROUND

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes.

METHODS

A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria.

RESULTS

A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports.

CONCLUSIONS

A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Use of Decision Analysis and Economic Evaluation in Breast Reconstruction: A Systematic Review

Background:

Decision analysis allows clinicians to compare different strategies in the context of uncertainty, through explicit and quantitative measures such as quality of life outcomes and costing data. This is especially important in breast reconstruction, where multiple strategies can be offered to patients. This systematic review aims to appraise and review the different decision analytic models used in breast reconstruction.

Methods:

A search of English articles in PubMed, Ovid, and Embase databases was performed. All articles regardless of date of publishing were considered. Two reviewers independently assessed each article, based on strict inclusion criteria.

Results:

Out of 442 articles identified, 27 fit within the inclusion criteria. These were then grouped according to aspects of breast reconstruction, with implant-based reconstruction (n = 13) being the most commonly reported. Decision analysis (n = 19) and/or economic analyses (n = 27) were employed to discuss reconstructive options. The most common outcome was cost (n = 27). The decision analysis models compared and contrasted surgical strategies, management options, and novel adjuncts.

Conclusions:

Decision analysis in breast reconstruction is growing exponentially.The most common model used was a simple decision tree. Models published were of high quality but could be improved with a more in-depth sensitivity analysis. It is essential for surgeons to familiarize themselves with the concept of decision analysis to better tackle complicated decisions, due to its intrinsic advantage of being able to weigh risks and benefits of multiple strategies while using probabilistic models.