Blythe Robin, Cook David, Graves Nicholas
Australian Centre for Health Services Innovation, School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.
Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
F1000Res. 2018 Apr 26;7:500. doi: 10.12688/f1000research.14619.2. eCollection 2018.
A sepsis care bundle of intravenous vitamin C, thiamine, and hydrocortisone was reported to improve treatment outcomes. The data to support it are uncertain and decision makers are likely to be cautious about adopting it. The objective of this study was to model the opportunity costs in dollars and lives of waiting for better information before adopting the bundle.
A decision tree was built using information from the literature. We modelled the impact of bundle adoption under three scenarios using a simulation in which the bundle was effective as reported in the primary trial, less effective based on other information, and ineffective. The measurements were health services costs, quality-adjusted life years, and transition probabilities.
If the bundle proves to be effective under either scenario, it will save billions of dollars and millions of life-years in the United States. This is the opportunity cost of delaying an adoption decision and waiting for better quality evidence. We suggest that hospital decision-makers consider implementing the bundle on a trial basis while monitoring costs and outcomes data even while the evidence base is uncertain.
If the decision maker is unwilling to use the best available evidence now, but rather wishes to wait for definitive evidence they are risking incurring large costs for health care systems and for the patients they serve. An explicit analysis of uncertain clinical outcomes is a useful adjunct to guide decision making where there is clinical ambiguity. This approach offers a valid alternative to the default of clinical inactivity when faced with uncertainty.
据报道，包含静脉注射维生素C、硫胺素和氢化可的松的脓毒症治疗集束方案可改善治疗效果。支持该方案的数据并不确定，决策者在采用时可能会持谨慎态度。本研究的目的是模拟在采用该集束方案之前等待更完善信息所产生的金钱和生命方面的机会成本。
利用文献中的信息构建决策树。我们通过模拟三种情景来建模采用该集束方案的影响，这三种情景分别为：该集束方案如在初步试验中所报道的那样有效、根据其他信息效果较差以及无效。测量指标包括医疗服务成本、质量调整生命年和转移概率。
如果该集束方案在任何一种情景下被证明是有效的，那么在美国将节省数十亿美元和数百万生命年。这就是推迟采用决策并等待更高质量证据所产生的机会成本。我们建议医院决策者在监测成本和结果数据的同时，考虑在试验基础上实施该集束方案，即便证据基础尚不确定。
如果决策者现在不愿使用现有最佳证据，而是希望等待确凿证据，那么他们将冒着给医疗系统及其所服务的患者带来巨大成本的风险。对不确定的临床结果进行明确分析是在临床存在模糊性时指导决策的有用辅助手段。当面临不确定性时，这种方法为默认的临床不作为提供了一种有效的替代方案。
