Hoomans Ties, Severens Johan L, Evers Silvia M A A, Ament Andre J H A
Department of Health Organisation, Policy, and Economics, Maastricht University, Maastricht, the Netherlands.
Med Decis Making. 2009 Mar-Apr;29(2):207-16. doi: 10.1177/0272989X08327397. Epub 2009 Feb 23.
Decisions about clinical practice change, that is, which guidelines to adopt and how to implement them, can be made sequentially or simultaneously. Decision makers adopting a sequential approach first compare the costs and effects of alternative guidelines to select the best set of guideline recommendations for patient management and subsequently examine the implementation costs and effects to choose the best strategy to implement the selected guideline. In an integral approach, decision makers simultaneously decide about the guideline and the implementation strategy on the basis of the overall value for money in changing clinical practice. This article demonstrates that the decision to use a sequential v. an integral approach affects the need for detailed information and the complexity of the decision analytic process. More importantly, it may lead to different choices of guidelines and implementation strategies for clinical practice change. The differences in decision making and decision analysis between the alternative approaches are comprehensively illustrated using 2 hypothetical examples. We argue that, in most cases, an integral approach to deciding about change in clinical practice is preferred, as this provides more efficient use of scarce health-care resources.
关于临床实践变革的决策，即采用哪些指南以及如何实施这些指南，可以按顺序或同时做出。采用顺序法的决策者首先比较替代指南的成本和效果，以选择用于患者管理的最佳指南建议集，随后检查实施成本和效果，以选择实施所选指南的最佳策略。在整体法中，决策者基于改变临床实践的总体性价比，同时决定指南和实施策略。本文表明，采用顺序法还是整体法的决策会影响对详细信息的需求以及决策分析过程的复杂性。更重要的是，它可能导致临床实践变革中指南和实施策略的不同选择。使用两个假设示例全面说明了替代方法之间在决策制定和决策分析方面的差异。我们认为，在大多数情况下，采用整体法来决定临床实践的变革更为可取，因为这能更有效地利用稀缺的医疗保健资源。
