Department of Operating Rooms, Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Nijmegen, The Netherlands.
Radboud University Student Biomedical Sciences, Nijmegen, The Netherlands.
Ann Surg. 2019 Mar;269(3):530-536. doi: 10.1097/SLA.0000000000002553.
To illustrate how decision modeling may identify relevant uncertainty and can preclude or identify areas of future research in surgery.
To optimize use of research resources, a tool is needed that assists in identifying relevant uncertainties and the added value of reducing these uncertainties.
The clinical pathway for laparoscopic distal pancreatectomy (LDP) versus open (ODP) for nonmalignant lesions was modeled in a decision tree. Cost-effectiveness based on complications, hospital stay, costs, quality of life, and survival was analyzed. The effect of existing uncertainty on the cost-effectiveness was addressed, as well as the expected value of eliminating uncertainties.
Based on 29 nonrandomized studies (3.701 patients) the model shows that LDP is more cost-effective compared with ODP. Scenarios in which LDP does not outperform ODP for cost-effectiveness seem unrealistic, e.g., a 30-day mortality rate of 1.79 times higher after LDP as compared with ODP, conversion in 62.2%, surgically repair of incisional hernias in 21% after LDP, or an average 2.3 days longer hospital stay after LDP than after ODP. Taking all uncertainty into account, LDP remained more cost-effective. Minimizing these uncertainties did not change the outcome.
The results show how decision analytical modeling can help to identify relevant uncertainty and guide decisions for future research in surgery. Based on the current available evidence, a randomized clinical trial on complications, hospital stay, costs, quality of life, and survival is highly unlikely to change the conclusion that LDP is more cost-effective than ODP.
说明决策模型如何识别相关不确定性，并排除或确定手术领域未来研究的方向。
为了优化研究资源的利用，需要一种工具来帮助识别相关的不确定性和减少这些不确定性的附加值。
采用决策树对腹腔镜下胰体尾切除术（LDP）与开放性（ODP）治疗非恶性病变的临床路径进行建模。基于并发症、住院时间、成本、生活质量和生存率进行成本效益分析。分析了现有不确定性对成本效益的影响，以及消除不确定性的预期价值。
基于 29 项非随机研究（3701 例患者），该模型表明 LDP 比 ODP 更具成本效益。LDP 在成本效益方面不如 ODP 的情况似乎不太现实，例如，LDP 后 30 天死亡率比 ODP 高 1.79 倍，转换率为 62.2%，LDP 后切口疝修补率为 21%，或 LDP 后住院时间平均比 ODP 长 2.3 天。考虑到所有的不确定性，LDP 仍然更具成本效益。最小化这些不确定性并没有改变结果。
结果表明，决策分析模型如何帮助识别相关的不确定性，并为手术领域的未来研究提供决策指导。基于目前现有的证据，关于并发症、住院时间、成本、生活质量和生存率的随机临床试验极不可能改变 LDP 比 ODP 更具成本效益的结论。
