Djulbegovic Benjamin, Hozo Iztok, Lizarraga David, Guyatt Gordon
Department of Computational & Quantitative Medicine, Beckman Research Institute, Duarte, California, USA.
Division of Health Analytics, Duarte, California, USA.
J Eval Clin Pract. 2023 Apr;29(3):459-471. doi: 10.1111/jep.13809. Epub 2023 Jan 24.
RATIONALE, AIMS AND OBJECTIVES: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision-theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling.
Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast-and-frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d-dimer → computerized pulmonary angiography (CTPA) ('ASH-Low') versus CTPA→ d-dimer ('ASH-High') versus treat without testing.
Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE < 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models.
CPG panels rely on various decision-theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision-making modelling.
原理、目的和目标：临床实践指南（CPG）的制定缺乏一个明确且透明的框架来综合制定实践建议所需的关键要素。我们将美国血液学会（ASH）CPG小组关于肺栓塞（PE）管理的审议与相应的决策理论结构进行匹配，以评估小组建议与明确决策模型的一致性。
确定了五种结构，其中三种用于重新制定小组的建议：（1）标准的预期效用阈值（EUT）决策模型；（2）可接受遗憾阈值模型（ARg），以确定可容忍的假阴性（FN）或假阳性（FP）建议的频率，以及（3）快速节俭树（FFT）决策树，以制定PE管理的整体策略。我们比较了四种管理策略：不进行检测与D - 二聚体→计算机断层扫描肺动脉造影（CTPA）（“ASH - 低”）与CTPA→D - 二聚体（“ASH - 高”）与不检测直接治疗。
不同模型产生了不同的建议。例如，根据EUT，对于PE的先验概率<0.13%应不进行检测，这是一个临床上不可行的阈值，比ASH指南排除PE的阈值（PE后验概率≤2%）低多达15倍（2/0.13）。三种模型仅一致认为，对于PE的检测前概率在0.13%至13.27%之间应使用“ASH低”策略，而对于先验PE概率在90.85%至93.07%的狭窄范围内应采用“ASH高”管理。对于所有其他PE的先验概率，选择一种模型并不能确保与其他模型的一致性。
CPG小组依靠各种决策理论策略来制定其建议。如果CPG小组在制定指南时的审议保持必要的一致性，分解CPG小组的审议可以提供见解。CPG建议通常与广泛用于医疗决策建模的EUT决策分析不一致。
