Diaz-Ledezma Claudio, Lichstein Paul M, Dolan James G, Parvizi Javad
The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
Clin Orthop Relat Res. 2014 Nov;472(11):3275-84. doi: 10.1007/s11999-014-3492-2.
In the setting of finite healthcare resources, developing cost-efficient strategies for periprosthetic joint infection (PJI) diagnosis is paramount. The current levels of knowledge allow for PJI diagnostic recommendations based on scientific evidence but do not consider the benefits, opportunities, costs, and risks of the different diagnostic alternatives.
QUESTIONS/PURPOSES: We determined the best diagnostic strategy for knee and hip PJI in the ambulatory setting for Medicare patients, utilizing benefits, opportunities, costs, and risks evaluation through multicriteria decision analysis (MCDA).
The PJI diagnostic definition supported by the Musculoskeletal Infection Society was employed for the MCDA. Using a preclinical model, we evaluated three diagnostic strategies that can be conducted in a Medicare patient seen in the outpatient clinical setting complaining of a painful TKA or THA. Strategies were (1) screening with serum markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]) followed by arthrocentesis in positive cases, (2) immediate arthrocentesis, and (3) serum markers requested simultaneously with arthrocentesis. MCDA was conducted through the analytic hierarchy process, comparing the diagnostic strategies in terms of benefits, opportunities, costs, and risks.
Strategy 1 was the best alternative to diagnose knee PJI among Medicare patients (normalized value: 0.490), followed by Strategy 3 (normalized value: 0.403) and then Strategy 2 (normalized value: 0.106). The same ranking of alternatives was observed for the hip PJI model (normalized value: 0.487, 0.405, and 0.107, respectively). The sensitivity analysis found this sequence to be robust with respect to benefits, opportunities, and risks. However, if during the decision-making process, cost savings was given a priority of higher than 54%, the ranking for the preferred diagnostic strategy changed.
After considering the benefits, opportunities, costs, and risks of the different available alternatives, our preclinical model supports the American Academy of Orthopaedic Surgeons recommendations regarding the use of serum markers (ESR/CRP) before arthrocentesis as the best diagnostic strategy for PJI among Medicare patients.
Level II, economic and decision analysis. See Instructions to Authors for a complete description of levels of evidence.
在医疗资源有限的情况下，制定具有成本效益的人工关节周围感染（PJI）诊断策略至关重要。目前的知识水平允许基于科学证据提出PJI诊断建议，但未考虑不同诊断方法的益处、机会、成本和风险。
问题/目的：我们通过多标准决策分析（MCDA）评估益处、机会、成本和风险，确定了医疗保险患者门诊环境中膝关节和髋关节PJI的最佳诊断策略。
MCDA采用肌肉骨骼感染学会支持的PJI诊断定义。使用临床前模型，我们评估了三种可在门诊临床环境中就诊的医疗保险患者中实施的诊断策略，这些患者主诉全膝关节置换术（TKA）或全髋关节置换术（THA）疼痛。策略分别为：（1）用血清标志物（红细胞沉降率[ESR]/C反应蛋白[CRP]）筛查，阳性病例随后进行关节穿刺；（2）立即进行关节穿刺；（3）关节穿刺同时检测血清标志物。通过层次分析法进行MCDA，比较诊断策略在益处、机会、成本和风险方面的差异。
策略1是医疗保险患者中诊断膝关节PJI的最佳选择（归一化值：0.490），其次是策略3（归一化值：0.403），然后是策略2（归一化值：0.106）。髋关节PJI模型中各选择的排名相同（归一化值分别为0.487、0.405和0.107）。敏感性分析发现，该顺序在益处、机会和风险方面具有稳健性。然而，如果在决策过程中，成本节约的优先级高于54%，则首选诊断策略的排名会发生变化。
在考虑了不同可用方法的益处、机会、成本和风险后，我们的临床前模型支持美国矫形外科医师学会关于在关节穿刺前使用血清标志物（ESR/CRP）作为医疗保险患者中PJI最佳诊断策略的建议。
二级，经济和决策分析。有关证据水平的完整描述，请参阅作者指南。
