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Medical Decision Making

Primer on Medical Decision Analysis: Part 1−−Getting Started

Allan S. Detsky, Gary Naglie, Murray D. Krahn, David Naimark and Donald A. Redelmeier
Med Decis Making 1997 17: 123
DOI: 10.1177/0272989X9701700201
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For example. evaluating the tree. Naglie and Krahn are partially supported by Arthur Bond Fellowships from the Physicians’ Services Incorporated Foundation. In this series9-&dquo. MD.sagepub. our group at the University of Toronto has taught a one-semester course on decision analysis. This requires building a decision tree on paper. modeling that tree on a computer. DETSKY. ON M5G 2C4. not just read at HAM-TMC LIBRARY on November 13. When Is Decision Received December 27. ( 14 we attempt to impart what we.1-s To pass the course. patients who have carotid artery stenosis of more than 70% after suffering transient ischemic attacks clearly benefit from carotid endarterectomy. EN G-246.Tutorial: How to Primer on Medical Decision Part Perform a Decision Analysis Analysis: 1&mdash. Part 1 introduces the topic and covers questions such as choosing an appropriate question. decision trees. respectively. Before embarking on this series. Several of the students have gone on to publish their work. probability. Address correspondence and reprint requests to Dr. Analysis Appropriate? One of the first steps in a decision analysis is to decide whether the technique is appropriate for the given question. each student is required to develop a model that &dquo. presenting the study to peers. and threshold analyses. Toronto. Much of what we have develop a come working ysis. The series assumes that the reader is already familiar with the concepts of decision analysis and has read and comprehended several decision analyses before trying his or her hand at one. tree representation. Revision accepted for publication December 12. General Division. there should be some uncertainty about the appropriate clinical strategy for patients with a given health state. as learned has from teaching our students how model. and writing up the analysis.1718 The goal of the present series is to give practical suggestions for performing decision anal- Over the past ten years. performing sensitivity analyses. Medicine.Getting Started ALLAN S. have learned about the practical issues of performing decision analysis. The Toronto Hospital. Canada. MS(HSR) This paper is Part 1 of a five-part series covering practical issues in the performance of decision analysis. obtaining probabilities and utilities by direct measurement or literature review. Ontario. Unlike educational initiatives that solely focus on readings about and discussions of to decision analysis. MD.&dquo. 200 Elizabeth Street. sensitivity. PhD. The series assumes familiarity with the basic concepts of decision analysis. It imparts many of the recommendations the authors have learned in teaching a one-semester course in decision analysis to graduate students. Drs Detsky and Redelmeier are partially supported by Career Awards from the National Health Research and Development Programme and the Ontario Ministry of Health. Canada e-mail. as demonstrated by the NASCET toronto. The intended audience is individuals who are learning how to perform decision analyses. and deciding on a time frame. expected value. (Med Decis Making 1997. Toronto. Two issues merit special attention. 123 Downloaded from mdm. Key words: decision analysis. There are some circumstances in clinical medicine when published primary clinical evidence already clearly identifies the optimal clinical strategy. MSc. and the accompanying note on presentation. and is also referred to two textbooks. GARY NAGLIE. 1995. and Clinical Biochemistry. our course has required that each student perform a decision analysis. probability nodes. 2013 . the reader should read a two-part users’ guide aimed at consumers of decision analyses 15 16 to achieve a grounding in basic concepts such as decision nodes. MD. KRAHN. First. The intended audience for this series is individuals who are learning how to perform decision analyses. MD. Detsky. Drs. MD. REDELMEIER. DONALD A. 1996. determining the tradeoff between accuracy and simplicity. from the University of Toronto Programme in Clinical Epidemiology and Health Care Research (The Toronto Hospital and The Sunnybrook Health Science Centre Units) and the Departments of Health Administration. sensitivity analysis. expected value. utility. DAVID NAIMARK. MURRAY D.

Most clinical studies including randomized trials have relatively limited time frames. Sometimes randomized trials have been performed but the optimal decision remains uncertain because several outcomes are involved. In this circumstance.. If one strategy clearly dominates the other because it re- sults in lower rates of adverse disease outcomes. data for such a such as a Markov model (described tree. one strategy may clearly be better than the other in the clinical sense but result in higher expected costs. in some trials. For example. it may be wise to develop a simpler model. Decision analyses always require comparison of at least two clinical strategies.21 we have often found that the insights derived from a simple model are similar to those derived from a complex formulation. When considering therapeutic strategies to avoid short-term complications (e. and performing a ventilation-perfusion lung scan and going on to angiography only if its result is neither clearly positive (high-probability scan) nor clearly negative (normal scan). A decision analysis20 can incorporate these three outcomes as well as possible different levels of risk depending on patient characteristics (e. clearly supported by are direct evidence. namely desire for completeness versus availability of data. however. analysts will wish ity of data. We encourage beginners to develop the simplest at HAM-TMC LIBRARY on November 13. However. preventing Accuracy versus Simplicity Decision-analytic models must be sufficiently complex to incorporate the important events and values. anticoagulating without further tests. The second main issue in assessing the potential value of a decision analysis is to ensure that there is a meaningful tradeoff in the problem. yet sufficiently simple to be understandable. If a key element of the riskbenefit tradeoff is missing. Like others. one might consider only three options in the pulmonary embolism example: doing nothing further. a considerable dropout because patients do not wish to be on coumadin for indefinite periods of time. Of course. but rather a simplified and highly stylized model of the most important components. In this series. the period of observation is usually between one and three years and rarely as long as five years. but Downloaded from mdm. a simple model would consider empirically anticoagulating the patient. The randomized trials of anticoagulation in atrial fibrillation. other existing cardiac disease).. for example.’9 One need this not perform a decision analysis of most clinical decisions question. A second major consideration concerns availabilsome circumstances. can In choosing an appropriate time depend upon frame. In models to better fit the problem.the real world&dquo. venous to develop complex more nature of the doppler ultrasonography. then a decision analysis is not necessary. we focus on models that have only one clinical outcome measure. the analyst must determine an appropriate time frame. the model will not achieve its goal of helping the reader understand the tradeoff. or performing tests such as a ventilation-perfusion lung scan. 2013 .g. and angiography. in suspected pulmonary embolism. An example of this situation might be a noninvasive diagnostic technique (such as echocardiography) compared with an equally accurate but more invasive diagnostic technique (such as angiography) for assessing myocardial wall motion or thickness. the time frame will the nature of the clinical problem. impedence plethysmography. the analyst must consider whether the model captures the key issues necessary to fully describe the risk-benefit tradeoff. less risk of treatment side effects and better utilities. the time frame be brief. Thus. In these circumstances. Thus. Occasionally one gets reports of long-term follow-up.sagepub. one con- fronts the same tradeoff as noted in the above section on accuracy versus simplicity. the time frame should be long. complex in Part 5 of this series)13 that uses transition probabilities from one state to another over successive short time periods. Such a model can help the decision maker understand the not as risk-benefit tradeoff more explicitly. One strategy ought to contain advantages and countervailing disadvantages. How many strategic alternatives should be included ? Some clinical questions require consideration of multiple combinations of several interventions. When considering alternative strategies for treating chronic illnesses.124 Trial. A decision tree is not a complete representation of &dquo. or perioperative management issues). are often unavailable.g. show a reduction in the risk of stroke but an increased risk of bleeding and. age. One can always add other options later on. The various combinations would result in dozens of possible strategies. To determine the appropriate level of complexity. The best approach for modeling such a circumstance is to limit the number of options to those that are clearly different from each other and cover the spectrum of the problem. However. decision-analytic models can also be used to estimate the cost-effectiveness of interventions involving dual outcomes such as costs and utilities. Even for trials involving chronic diseases such as coronary artery disease. Time Frame In comparing outcomes of alternative strategies.

Read SE.getting started Med Decis Making. Guerriere M.148:370-7 Barrett BJ. Percutaneous injuries among health care workers: the real value of HIV testing of "donor" blood.1610-3.17:152-9. Richardson WS. Beneficial effect of carotid endar- 1992. Tu Phil- PA: W. 4. have much longer periods of observation.273.17. North American Management of suspected giant at HAM-TMC LIBRARY on November 13. B. MC. Med Decis Making. VII How to use a clinical decision analysis. Buchbinder R. 1992. Detsky AS Surgical decision analysis: esophagectomy/ carimi Naglie G. Marton KI. Detsky AS. 11 17:142-51. analysis. Fineberg HV. Arch Intern Med. Detsky AS. Most analysts will have to extend the period of observation of a randomized trial for their analysis and therefore will have to extrapolate the data. aggressive (U. N 20 Yusuf S. Redelmeier DA. Users’ guides to the medical literature. Naimark D.4:530 stenosis. 9.228-30. 15 Richardson WS. Am J Med Sci. Peduzzi P. Med Decis 325-35. J Rheumatol. Parfrey PS. England: Butterworth & Co. Carotid terectomy in symptomatic patients with high-grade carotid 22. UD.115:248-55. which describes the among a tervals or transitions number of health states cycles. Detsky AS. B Results and appli- Olak J. Krahn MD. Lau J. Are the results of the study valid? JAMA. Blatt MA. Lancet 1994. Naimark D. Ann Intern Med. Detsky AS. 1997. Can "hypersimplified" decision trees be used instead of Markov models? [abstr]. 1992. Detsky AS. Higgins MC.22 Some cohort studies. Clinical Decision cability 17 Weinstein Ann Thorac Surg.14 Krahn MD. 19. 5. and the Evidence-Based Medicine Working Group. et al.analyzing the model and interpreting the results. Detsky AS. Naimark D. Detsky AS. 1991. a decision JAMA 1995. Making. 1990.17. 1984. a modeling technique derived from matrix alge- bra. Warde P. Allen Krahn MD. such as the Framingham Study. Zucker D. Pauker SG. Basinski AS. Analysis. Treatment of chronic nonvalvular atrial fibrillation in the elderly: a decision analysis. Naimark D.325:445-53. 13 esophagogastrectomy with without or a drainage? 18. mer on 40. Downloaded from mdm. Redelmeier D. Naglie G.12:239-49. 1997. Primer on medical decision analysis: Part 5&mdash. Armstrong PW Management of asymp- tomatic chronic aortic function: a regurgitation with left ventricular dysanalysis. 14. Detsky AS. and the Evidence-Based Medicine Working Group. Dunn VH. London. How to use a clinical decision analysis. Biem Primer on medical decision analysis: Part Med Decis Making.S ) and 1991.building a tree. 1995.sagepub. pneumonia a decision analysis Am Rev Respir Dis Endarterectomy Trial Engl J Med. Detsky AS. Naglie G. 2013 a cohort of patients make a series of short in- during . an Naylor CD.5:394- decision 401. Detsky AS. Naglie G. Users’ guides to the medical literature VII.273:1292-5.125 the observation periods in these reports rarely exceed ten years.123-5. Guidelines for verbal presentations of medical decision analyses. Med Decis Making. important. Krahn MD. therefore. 1. 10. The performance of extensive sensitivity analyses around these extrapolations is References HJ.136-41. 1992.17:126-35. Naglie G. Sox H. Naglie G.304 8 Naimark D. Med Decis Making.17. Glossary Markov Model: A decision-analytic model that involves a Markov process. Primedical decision analysis: Part 3&mdash. Med Decis Making. diag- 1994. Redelmeier D. 1997. cell arteritis.151:2033- 3. 2. 1988.estimating probabilities and utilities. Detsky AS Comparison of a less aggressive (Canadian) policy for cholesterol screening and treatment. 12. must balance the desire for complete long-term follow-up with the availability of valid and precise data. Naimark D. 16. One. 1997. Foley RN.53:493-7. Effect of coronary artery bypass surgery on survival overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. JV. Biem HJ.working with Markov processes. Redelmeier D. Detsky AS. Redelmeier D. Krahn MD. 1997. Detsky AS Bronchoscopy vs empirical therapy in HIV-infected patients with presumptive Pneumocystis Symptomatic (NASCET) Collaborators. Is steroid receptor data useful in patients with metastatic breast cancer. Naglie IG. 21 9-13 6. An economic analysis of strategies for the use of contrast media for nostic cardiac catheterization. 1980. Saunders. 1991. Redelmeier. Med Decis Making. J Gen Intern Med. Medical Decision Making. adelphia. Krahn M. Detsky AS. 1993.. Krahn MD. Moskowitz AJ. Primer on medical decision analysis: Part 1&mdash. Detsky AS Primer on medical decision analysis: Part 4&mdash. Med Decis Making. 2&mdash. Detsky AS. 7. 1997. A.19.