Firoz Bahar F, Lee Stephanie J, Nghiem Paul, Qureshi Abrar A
Department of Dermatology, New York University, New York, USA.
Arch Dermatol. 2006 Feb;142(2):175-82. doi: 10.1001/archderm.142.2.175.
To estimate the value of skin biopsy in the evaluation of suspected acute cutaneous graft-vs-host disease (GVHD) after allogeneic stem cell transplantation.
Decision analysis using parameters specified by expert opinion for skin biopsy characteristics, prevalence of acute GVHD, and value of potential outcomes. One-, 2-, and 3-way sensitivity analyses were performed.
Major stem cell transplantation centers in the United States.
Hypothetical cohort of patients with suspected acute cutaneous GVHD after stem cell transplantation.
The following 3 interventions were compared: treat immediately for GVHD without performing a skin biopsy, perform a skin biopsy and treat immediately but stop treatment if skin biopsy specimen findings are inconsistent with GVHD, and perform a skin biopsy and await results of the skin biopsy specimen before treating.
Number of patients appropriately and inappropriately treated with each intervention, consistency of physician-reported behavior, individualized decision analyses, and preferred intervention based on the aggregate estimates of respondents.
The decision to treat immediately for GVHD without performing a skin biopsy yielded the best clinical outcome for the specified clinical setting and under the parameters specified by expert opinion. One-way sensitivity analyses showed that these conclusions are robust if the prevalence of acute cutaneous GVHD in stem cell recipients with rash is greater than 50%, if the sensitivity of skin biopsy specimen is less than 0.8, and the specificity of skin biopsy specimen is less than 0.9. Only 25% of physicians interviewed chose an intervention consistent with their estimates of prevalence, test characteristics, and outcome evaluations, indicating an opportunity to improve management of this important clinical condition.
This decision analysis modeling technique predicts that in patient populations in which the prevalence of GVHD is 30% or greater (typical for allogeneic stem cell transplantation), the best outcomes were obtained with treatment for GVHD and no skin biopsy. In populations with prevalence of GVHD of 30% or less, obtaining a skin biopsy specimen to guide treatment was predicted to provide the best patient outcomes.
评估皮肤活检在异基因干细胞移植后疑似急性皮肤移植物抗宿主病（GVHD）评估中的价值。
采用专家意见指定的皮肤活检特征、急性GVHD患病率及潜在结果价值等参数进行决策分析。进行了单因素、双因素和三因素敏感性分析。
美国主要的干细胞移植中心。
干细胞移植后疑似急性皮肤GVHD的假设队列患者。
比较以下3种干预措施：不进行皮肤活检立即治疗GVHD；进行皮肤活检并立即治疗，但如果皮肤活检标本结果与GVHD不一致则停止治疗；进行皮肤活检并等待皮肤活检标本结果再进行治疗。
每种干预措施适当治疗和不适当治疗的患者数量、医生报告行为的一致性、个体化决策分析以及基于受访者总体估计的首选干预措施。
在特定临床环境和专家意见指定的参数下，不进行皮肤活检立即治疗GVHD的决策产生了最佳临床结果。单因素敏感性分析表明，如果皮疹干细胞受体中急性皮肤GVHD的患病率大于50%，皮肤活检标本的敏感性小于0.8，且皮肤活检标本的特异性小于0.9，这些结论是可靠的。接受访谈的医生中只有25%选择了与其对患病率、检测特征和结果评估的估计一致的干预措施，这表明有机会改善这种重要临床情况的管理。
该决策分析建模技术预测，在GVHD患病率为30%或更高的患者群体中（异基因干细胞移植的典型情况），不进行皮肤活检治疗GVHD可获得最佳结果。在GVHD患病率为30%或更低的群体中，预计获取皮肤活检标本以指导治疗可提供最佳患者结果。
