A 65-year-old Chinese woman with lymphadenopathy and progressive pulmonary infiltrates. One million Chinese women can't all have tuberculosis

Mediastinal staging in non-small-cell lung cancer

Decision analysis was used to study the approach to staging mediastinal involvement in patients with non-small-cell lung cancer (NSCLC). Various diagnostic strategies for mediastinal disease staging using computed tomography (CT), mediastinoscopy, and bronchoscopy with transbronchial needle aspiration (TBNA), either individually or in series, were compared and found to result in similar patient life expectancies. Two strategies, one using bronchoscopy and TBNA alone and the other using it in combination with CT, were consistently least expensive across a wide range of prior probabilities, test characteristics, and charges. The authors conclude that strategies for staging mediastinal involvement in NSCLC that rely on bronchoscopy and TBNA are preferable because they are least expensive.

Clinical decision consultation service

Since 1978, decision analysis consultations have been offered to help physicians manage particularly vexing clinical problems. Consultations were requested for decisions perceived as difficult because: the diagnosis was uncertain; the available therapy had uncertain efficacy or risks; the patient had a short life expectancy that limited the potential benefit of therapy; the risk of a given test or therapy was increased and the usual rules for applying the test or giving the treatment did not apply; the need for a therapeutic procedure was acknowledged, but competing risks created uncertainty about the optimal timing of the procedure; the optimal sequence of multiple necessary procedures could not be discerned readily; explicit patient input into decision-making was required; certain medical information could not be interpreted easily; and a rare, unique, or new problem was encountered. To carry out these consultations, standard techniques were used, including decision tree models, Bayes' theorem, Markov analysis, and utility assessment, but old approaches were modified to adapt decision analysis to individual patient problems. This experience demonstrates that decision analysis can be carried out effectively on a consultative basis for individual patients. A consultation service can also train analysts in decision-making and drive research in medical problem solving.