In search of tools to aid logical thinking and communicating about medical decision making

Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis

Objective

Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD.

Methods

A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000.

Results

The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations.

Conclusions

Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Using the theory of constraints' processes of ongoing improvement to address the provider appointment scheduling system execution problem

Many primary care clinics suffer from chaos. In scheduling, providers are continually trying unsuccessfully to balance supply and demand, and in execution, to manage disruptions to provider focus and patient flow. In this research the theory of constraints' (TOC) three processes of ongoing improvement (POOGI) provide a direction for the solution to achieving more, cheaper, better, and faster healthcare. This research is the second of a two-part study examining the appointment scheduling literature, identifying the core problem (using a case study for validation) and providing a generic process for developing effective provider appointment scheduling systems (PASS). In the first part, PASS design was studied and in this second part PASS execution is studied. A strawman process is developed to apply across outpatient medical practices. With this generic process implemented across outpatient scheduling systems cost could be reduced significantly while the quality and timeliness could be increased significantly.

Nerve transfer versus muscle transfer to restore elbow flexion after pan-brachial plexus injury: a cost-effectiveness analysis

OBJECTIVE Pan-brachial plexus injury (PBPI), involving C5-T1, disproportionately affects young males, causing lifelong disability and decreased quality of life. The restoration of elbow flexion remains a surgical priority for these patients. Within the first 6 months of injury, transfer of spinal accessory nerve (SAN) fascicles via a sural nerve graft or intercostal nerve (ICN) fascicles to the musculocutaneous nerve can restore elbow flexion. Beyond 1 year, free-functioning muscle transplantation (FFMT) of the gracilis muscle can be used to restore elbow flexion. The authors present the first cost-effectiveness model to directly compare the different treatment strategies available to a patient with PBPI. This model assesses the quality of life impact, surgical costs, and possible income recovered through restoration of elbow flexion. METHODS A Markov model was constructed to simulate a 25-year-old man with PBPI without signs of recovery 4.5 months after injury. The management options available to the patient were SAN transfer, ICN transfer, delayed FFMT, or no treatment. Probabilities of surgical success rates, quality of life measurements, and disability were derived from the published literature. Cost-effectiveness was defined using incremental cost-effectiveness ratios (ICERs) defined by the ratio between costs of a treatment strategy and quality-adjusted life years (QALYs) gained. A strategy was considered cost-effective if it yielded an ICER less than a willingness-to-pay of $50,000/QALY gained. Probabilistic sensitivity analysis (PSA) was performed to address parameter uncertainty. RESULTS The base case model demonstrated a lifetime QALYs of 22.45 in the SAN group, 22.0 in the ICN group, 22.3 in the FFMT group, and 21.3 in the no-treatment group. The lifetime costs of income lost through disability and interventional/rehabilitation costs were $683,400 in the SAN group, $727,400 in the ICN group, $704,900 in the FFMT group, and $783,700 in the no-treatment group. Each of the interventional modalities was able to dramatically improve quality of life and decrease lifelong costs. A Monte Carlo PSA demonstrated that at a willingness-to-pay of $50,000/QALY gained, SAN transfer dominated in 88.5% of iterations, FFMT dominated in 7.5% of iterations, ICN dominated in 3.5% of iterations, and no treatment dominated in 0.5% of iterations. CONCLUSIONS This model demonstrates that nerve transfer surgery and muscle transplantation are cost-effective strategies in the management of PBPI. These reconstructive neurosurgical modalities can improve quality of life and lifelong earnings through decreasing disability.

Pipeline embolization device versus coiling for the treatment of large and giant unruptured intracranial aneurysms: a cost-effectiveness analysis

OBJECTIVE Rupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms. METHODS A Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS The base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations. CONCLUSIONS The authors' cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.

Antineoplastic Agents and (In)fertility: Informing Patients to Improve Decisions

PURPOSE

Infertility is a potential adverse effect of cancer treatment, and future fertility is an important issue for cancer patients. In Portugal, the Centre for Fertility Preservation of CHUC, EPE, conducted a project to develop and disseminate oncofertility information resources. In this study, we report the results of the specific component of this program, which intended to produce information resources that promote patients' awareness of the subject and to support decisions concerning fertility preservation.

METHODS

Guidance for writing health information for patients and criteria for developing decision aids were gathered. Information needs were assessed (literature review and locally applied questionnaire). Resources were pre-tested with a sample of patients and professionals. Their readability, presentation quality, and ability to support decisions were evaluated.

RESULTS

General information handouts on infertility risk and decision aids about fertility preservation options were developed and positively evaluated. The resources are currently being distributed in collaboration with several national organizations.

CONCLUSIONS

Through our multidisciplinary information program, reproductive-age cancer patients now have access to relevant information resources that will support timely, shared decision-making concerning fertility preservation.

Using the Theory of Constraints to resolve long-standing resource and service issues in a large public hospital

Public health care providers typically struggle with the need to meet demand for services, within a limited budget. This paper describes an analysis of a large public hospital, using the Theory of Constraints' (TOC) comprehensive set of mapping tools to logically represent a problematic situation and investigate options for resolution. Based on the symptoms present, root causes and conflicts were identified, along with potential solutions. Further TOC tools were used to check for possible side effects of the solution, and identify obstacles that might impede successful implementation. Based on the TOC analysis, a trial project was implemented with significant benefits for two departments. Outcomes included dramatically reduced patient wait times and staff overtime, increased patient satisfaction, increased efficiencies, smoothed workload, and improved staff morale and retention, while maintaining patient safety and integrity of treatment, and staying within defined cost parameters.

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.

Medical and Nonmedical Determinants of Decision Making about Potentially Life-Prolonging Interventions

Patient characteristics may influence medical decision making in various ways. The contribution of several patient characteristics to medical decision making was studied. Thirty oncologists, 29 nursing home physicians, and 22 cardiologistswere interviewed (overall response = 60%). Respondents were asked whether they would apply a specified intervention for a number of hypothetical seriously ill patients, who varied with respect to factors thatwere not relevant to the outcome of treatment. The condition that made patients clearly eligible for treatment was kept constant. In amultivariate regression model, patients with a better physical condition, a more obvious social role, and a lower age weremore likely to be treated thanwere other patients. Medical decision making is not exclusively based on empirical evidence but also related to morally complex issues such as patient age and social status.

Structured shared decision-making using dialogue and visualization: a randomized controlled trial

OBJECTIVE

The aim of this study is to evaluate a method, "Counseling in Dialogue" (CD), developed to increase the quality of counseling in youth mental health. Decisional conflict was used as indicator of the quality of counseling and shared decision-making.

METHODS

94 children aged 2-12 years were randomized into a CD group and a care as usual (CU) group. In a before-and-after design decisional conflict was measured using the decisional conflict scale (DCS) for parents (N=133) and the Provider Decision Process Assessment Instrument for therapists (PDPAI, N=20). 81 children had follow-up data.

RESULTS

Compared with parents of the CU group, parents of the CD group reported significantly less decisional conflict after counseling (difference mothers: -0.38 (95%CI -0.56; -0.19), p<.001; fathers: -0.22 (95%CI -0.44; -0.01), p=.045). 98% of the mothers and 96% of the fathers in the CD group accepted the recommended treatment, compared to 71% (fathers) and 77% (mothers) in the CU group, p<0.05. Decisional conflict of the therapists was low in both groups after counseling (difference: -0.03 (95%CI -0.19; 0.14), p=.741).

CONCLUSION

The counseling procedure significantly lowered decisional conflict of the parents and promoted the acceptance of the recommended treatment.

Theory of constraints for publicly funded health systems

Originally developed in the context of publicly traded for-profit companies, theory of constraints (TOC) improves system performance through leveraging the constraint(s). While the theory seems to be a natural fit for resource-constrained publicly funded health systems, there is a lack of literature addressing the modifications required to adopt TOC and define the goal and performance measures. This paper develops a system dynamics representation of the classical TOC's system-wide goal and performance measures for publicly traded for-profit companies, which forms the basis for developing a similar model for publicly funded health systems. The model is then expanded to include some of the factors that affect system performance, providing a framework to apply TOC's process of ongoing improvement in publicly funded health systems. Future research is required to more accurately define the factors affecting system performance and populate the model with evidence-based estimates for various parameters in order to use the model to guide TOC's process of ongoing improvement.

The democratic fallacy in matters of clinical opinion: implications for analysing cause-of-death data

Arriving at a consensus between multiple clinical opinions concerning a particular case is a complex issue - and may give rise to manifestations of the democratic fallacy, whereby a majority opinion is misconstrued to represent some kind of "truth" and minority opinions are somehow "wrong". Procedures for handling multiple clinical opinions in epidemiological research are not well established, and care is needed to avoid logical errors. How to handle physicians' opinions on cause of death is one important domain of concern in this respect. Whether multiple opinions are a legal requirement, for example ahead of cremating a body, or used for supposedly greater rigour, for example in verbal autopsy interpretation, it is important to have a clear understanding of what unanimity or disagreement in findings might imply, and of how to aggregate case data accordingly.

In many settings where multiple physicians have interpreted verbal autopsy material, an over-riding goal of arriving at a single cause of death per case has been applied. In many instances this desire to constrain findings to a single cause per case has led to methodologically awkward devices such as "TB/AIDS" as a single cause. This has also usually meant that no sense of disagreements or uncertainties at the case level is taken forward into aggregated data analyses, and in many cases an "indeterminate" cause may be recorded which actually reflects a lack of agreement rather than a lack of data on possible cause(s).

In preparing verbal autopsy material for epidemiological analyses and public health interpretations, the possibility of multiple causes of death per case, and some sense of any disagreement or uncertainty encountered in interpretation at the case level, need to be captured and incorporated into overall findings, if evidence is not to be lost along the way. Similar considerations may apply in other epidemiological domains.

Grading the quality of evidence and the strength of recommendations in clinical dentistry: a critical review of 2 prominent approaches

The objective of this article was to critically review 2 prominent approaches used to grade the quality of evidence and the strength of recommendations. Every year much information becomes available as a result of publication of scientific papers, and clinicians should be able to assess current evidence so they, along with their patients, can make the most appropriate clinical decisions. This is particularly important when there is little or no high-quality evidence available about the subject of interest. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and the Strength of Recommendation Taxonomy (SORT) were evaluated. Strengths and weaknesses of these 2 systems are discussed, mainly on the basis of their relevance to clinical dentistry. The conclusion was that use of a system for grading the quality of evidence and the strength of recommendations is urgently required because of the great heterogeneity of the quality and type of evidence relating to many dental procedures. Use of such a system will enable clinicians and their patients to make more informed decisions.

Using decision trees to enhance interdisciplinary team work: the case of oncofertility

PURPOSE

Oncofertility, an emerging discipline at the intersection of cancer and fertility, strives to give cancer patients options when they are confronting potential infertility as a consequence of cancer treatment. Fertility preservation decisions must be made before treatment begins, adding stress to the decision-making process.

METHODS

Healthcare providers need to be aware of the intricacies involved in oncofertility decision making, and the often tight time line that patients face when making these decisions. Cancer patient's perspectives may also change, as the dual burden of a cancer diagnosis and potential infertility can cause great flux in emotions.

RESULTS

A provider-facing decision tree was created to enhance patient decision-making capacities and outline the multiple potential intervention points.

CONCLUSIONS

Decision trees, which highlight the important decision points during which providers can approach patients, can be a useful tool to help providers in counseling patients on fertility preservation.

A conceptual framework for evaluating information technologies and decision support systems for bioterrorism preparedness and response

OBJECTIVES

The authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist the key decisions faced by clinicians and public health officials preparing for and responding to bioterrorism.

METHODS

They reviewed reports of natural and bioterrorism related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify the key decisions, tasks, and information needs of clinicians and public health officials during a bioterrorism response. The authors used task decomposition to identify the subtasks and data requirements of IT/DSSs designed to facilitate a bioterrorism response. They used the results of the task decomposition to develop evaluation criteria for IT/DSSs for bioterrorism preparedness. They then applied these evaluation criteria to 341 reports of 217 existing IT/DSSs that could be used to support a bioterrorism response.

MAIN RESULTS

In response to bioterrorism, clinicians must make decisions in 4 critical domains (diagnosis, management, prevention, and reporting to public health), and public health officials must make decisions in 4 other domains (interpretation of bioterrorism surveillance data, outbreak investigation, outbreak control, and communication). The time horizons and utility functions for these decisions differ. From the task decomposition, the authors identified critical subtasks for each of the 8 decisions. For example, interpretation of diagnostic tests is an important subtask of diagnostic decision making that requires an understanding of the tests' sensitivity and specificity. Therefore, an evaluation criterion applied to reports of diagnostic IT/DSSs for bioterrorism asked whether the reports described the systems' sensitivity and specificity. Of the 217 existing IT/DSSs that could be used to respond to bioterrorism, 79 studies evaluated 58 systems for at least 1 performance metric.

CONCLUSIONS

The authors identified 8 key decisions that clinicians and public health officials must make in response to bioterrorism. When applying the evaluation system to 217 currently available IT/DSSs that could potentially support the decisions of clinicians and public health officials, the authors found that the literature provides little information about the accuracy of these systems.