类风湿关节炎的全腕关节置换术和全腕关节融合术：从手外科医生角度的决策分析
Total wrist arthroplasty and total wrist arthrodesis in rheumatoid arthritis: a decision analysis from the hand surgeons' perspective.
作者信息
Cavaliere Christi M, Chung Kevin C
机构信息
Department of Surgery, Section of Plastic Surgery, The University of Michigan Health System, Ann Arbor, MI 48109-0340, USA.
出版信息
J Hand Surg Am. 2008 Dec;33(10):1744-55, 1755.e1-2. doi: 10.1016/j.jhsa.2008.06.022.
PURPOSE
Treatment of severely destroyed rheumatoid wrists with total wrist arthroplasty or total wrist arthrodesis relies on patient and surgeon preferences rather than rigorous prospective outcomes data. The purpose of this study is to develop a decision analytic model of arthroplasty and arthrodesis in rheumatoid arthritis (RA) using utility values obtained from a random sample of hand surgeons.
METHODS
A utility survey using a time trade-off design was administered to 175 members of the American Society for Surgery of the Hand. Based on the results of the survey, the utility values that surgeons assign to health states associated with arthroplasty and arthrodesis and their complications were calculated. By combining utility values with complication rates in the published literature, we developed a decision tree to calculate the expected quality-adjusted life years (QALYs) for each procedure compared to living with a painful RA wrist.
RESULTS
Based on surgeon preferences, living for 30 years with a painful, poorly functioning RA wrist (utility = 0.54) is associated with 16.2 QALYs. Treatment with arthroplasty (utility = 0.85) is associated with 25.5 QALYs, a gain of 9.3 QALYs over nonsurgical management. Arthrodesis (utility = 0.82) is associated with 24.6 QALYs, a gain of 8.4 QALYs over nonsurgical management. Arthroplasty is associated with a small incremental increase in QALYs (0.9) compared to arthrodesis.
CONCLUSIONS
Based on utility scores, hand surgeons feel that living with a painful, poorly functioning RA wrist for 30 years is worth approximately half as many years with a painless, well-functioning wrist. The outcomes for arthroplasty and arthrodesis are valued more than nonsurgical management. On the basis of its higher expected gain in QALYs, arthroplasty should be the preferred treatment. The minimal increase in utility for arthroplasty over arthrodesis suggests however, that surgeons do not view arthroplasty as superior to arthrodesis.
TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis IV.
目的
采用全腕关节置换术或全腕关节融合术治疗严重受损的类风湿性腕关节，这取决于患者和外科医生的偏好，而非严格的前瞻性结果数据。本研究的目的是利用从手部外科医生随机样本中获得的效用值，建立类风湿关节炎（RA）关节置换术和关节融合术的决策分析模型。
方法
采用时间权衡设计对175名美国手外科协会成员进行效用调查。根据调查结果，计算外科医生赋予与关节置换术、关节融合术及其并发症相关健康状态的效用值。通过将效用值与已发表文献中的并发症发生率相结合，我们构建了一个决策树，以计算与患有疼痛性RA腕关节生活相比，每种手术的预期质量调整生命年（QALY）。
结果
根据外科医生的偏好，患有疼痛且功能不佳的RA腕关节生活30年（效用值 = 0.54）相当于16.2个QALY。关节置换术治疗（效用值 = 0.85）相当于25.5个QALY，比非手术治疗增加了9.3个QALY。关节融合术（效用值 = 0.82）相当于24.6个QALY，比非手术治疗增加了8.4个QALY。与关节融合术相比，关节置换术的QALY有小幅增量增加（0.9）。
结论
根据效用评分，手部外科医生认为，患有疼痛且功能不佳的RA腕关节生活30年，其价值约为无痛且功能良好腕关节生活年限的一半。关节置换术和关节融合术的结果比非手术治疗更受重视。基于其在QALY方面更高的预期收益，关节置换术应是首选治疗方法。然而，关节置换术与关节融合术相比效用增加最小，这表明外科医生并不认为关节置换术优于关节融合术。
研究类型/证据水平：经济与决策分析IV。
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