Mushlin A I, Littenberg B
University of Rochester Medical Center (AIM), New York.
J Gen Intern Med. 1994 Jan;9(1):1-7. doi: 10.1007/BF02599133.
To compare the efficacies and cost-effectiveness of four strategies for the management of suspected pedal osteomyelitis in the setting of vascular impairment: 1) therapeutic trial of short-term antibiotics for presumed cellulitis without osteomyelitis (short); 2) technetium bone scanning followed by either short-term therapy if negative or either a biopsy or aggressive long-term intravenous therapy if positive (scan); 3) bone biopsy followed by long-term intravenous therapy if positive or short-term therapy if negative (biopsy); and 4) immediate long-term intravenous antibiotics for presumed osteomyelitis (long).
Decision analysis and cost-effectiveness analysis with sensitivity analyses. The main outcomes states are amputation and the resource expenditures associated with bone scans, biopsies, and therapies.
The authors obtained estimates of test accuracy from literature review and summarized them using newly developed meta-analytic techniques.
The optimal decision depends heavily on the estimated probability of osteomyelitis at presentation. At very low probabilities, the short-term strategy is preferred. When the probability of osteomyelitis is from 2% to 8%, the lowest amputation rate occurs when one does a diagnostic scan. From 8% to 50%, the best outcomes follow biopsy. At probabilities higher than 50%, the preferred strategy is long-term antibiotics. However, the differences in outcomes are quite small even when osteomyelitis is a virtual certainty.
Over the whole range of prior probabilities, the short-term strategy is the least expensive. At very low probabilities, it dominates the other strategies. When the likelihood of osteomyelitis is higher (10-20%), scanning results in outcomes and cost-effectiveness ratios comparable to those of immediate biopsy and is less invasive. When the probability of osteomyelitis is 50%, biopsy is quite cost-effective compared with all the other strategies (cost-effectiveness ratio = $15,502 per amputation averted) and is preferred to the scan strategy. When the confidence that a patient has osteomyelitis is very high (> 90% probability), the improved outcomes associated with long-term antibiotics are achieved with little additional expense and with favorable cost-effectiveness ratios compared with those of the other strategies.
比较四种策略在血管损伤情况下处理疑似足部骨髓炎的疗效和成本效益：1）对假定为无骨髓炎的蜂窝织炎进行短期抗生素治疗试验（短期）；2）锝骨扫描，若结果为阴性则进行短期治疗，若为阳性则进行活检或积极的长期静脉治疗（扫描）；3）骨活检，若结果为阳性则进行长期静脉治疗，若为阴性则进行短期治疗（活检）；4）对假定的骨髓炎立即进行长期静脉抗生素治疗（长期）。
进行决策分析和成本效益分析，并进行敏感性分析。主要结局状态为截肢以及与骨扫描、活检和治疗相关的资源消耗。
作者通过文献综述获得检测准确性的估计值，并使用新开发的荟萃分析技术进行总结。
最佳决策在很大程度上取决于就诊时骨髓炎的估计概率。在概率非常低时，首选短期策略。当骨髓炎概率为2%至8%时，进行诊断性扫描时截肢率最低。概率从8%至50%时，活检后的结果最佳。概率高于50%时，首选策略是长期使用抗生素。然而，即使骨髓炎几乎可以确定，结果差异也相当小。
在整个先验概率范围内，短期策略成本最低。在概率非常低时，它优于其他策略。当骨髓炎可能性较高（10 - 20%）时，扫描的结果和成本效益比与立即活检相当，且侵入性较小。当骨髓炎概率为50%时，与所有其他策略相比，活检具有相当的成本效益（避免截肢的成本效益比 = 每例15,502美元），且优于扫描策略。当患者患有骨髓炎的确定性非常高（概率 > 90%）时，与其他策略相比，长期使用抗生素带来的改善结果只需很少的额外费用，且成本效益比良好。
