Sonnenberg Amnon, Bauerfeind Peter, Bakis Gennadiy
The Portland VA Medical Center, P3-GI, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA.
Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA.
Surg Endosc. 2023 Feb;37(2):1031-1037. doi: 10.1007/s00464-022-09599-8. Epub 2022 Sep 12.
Gastroenterologists frequently face the dilemma of how to choose among different management options.
To develop a tool of medical decision analysis that helps choosing between competing management options of interventional endoscopy and surgery.
Carcinoma-in-situ of the esophagus, large colonic polyps, and ampullary adenoma serve as three examples for disorders being managed by both techniques. A threshold analysis using a decision tree was modeled to compare the costs and utility values associated with managing the three examples. If the expected healing or success rate of interventional endoscopy exceeds a threshold calculated as the ratio of endoscopy costs over surgery costs, endoscopy becomes the preferred management option. A low threshold speaks in favor of endoscopic intervention as initial management strategy.
If the decision in favor of surgery is focused exclusively on preventing death from a given disease, surgical intervention may seem to provide the best treatment option. However, interventional endoscopy becomes a viable alternative, if the comparison is based on a broader perspective that includes adverse events and long-term disability, as well as the healthcare costs of both procedures. For carcinoma-in-situ of the esophagus, the threshold for the expected success rate is 24% (range in the sensitivity analysis: 7-29%); for large colonic polyps it is 10% (5-12%), and for duodenal papillary adenoma it is 17% (5-21%).
Even if a management strategy surpasses its alternative with respect to one important outcome parameter, there is often still room for the lesser alternative to be considered as viable option.
胃肠病学家经常面临如何在不同管理方案中进行选择的困境。
开发一种医学决策分析工具，以帮助在介入性内镜检查和手术这两种相互竞争的管理方案之间做出选择。
食管原位癌、大肠息肉和壶腹腺瘤作为两种技术都可治疗的疾病的三个例子。使用决策树进行阈值分析，以比较与处理这三个例子相关的成本和效用值。如果介入性内镜检查的预期愈合或成功率超过以内镜检查成本与手术成本之比计算得出的阈值，则内镜检查成为首选的管理方案。低阈值有利于将内镜干预作为初始管理策略。
如果仅将支持手术的决策重点放在预防特定疾病导致的死亡上，手术干预似乎可能是最佳治疗选择。然而，如果基于更广泛的视角进行比较，包括不良事件、长期残疾以及两种手术的医疗成本，介入性内镜检查就成为一种可行的替代方案。对于食管原位癌，预期成功率的阈值为24%（敏感性分析范围：7%-29%）；对于大肠息肉，为10%（5%-12%），对于十二指肠乳头腺瘤，为17%（5%-21%）。
即使一种管理策略在一个重要结果参数方面超过了其替代方案，通常较小的替代方案仍有被视为可行选择的空间。
