Brasel K J, Borgstrom D C, Weigelt J A
St. Paul-Ramsey Medical Center, University of Minnesota 55101, USA.
J Am Coll Surg. 1997 Jan;184(1):23-30.
The influence of patient preference and treatment costs has not been considered in previous analyses of wound management decisions for contaminated right lower quadrant incisions.
We performed a decision and cost-utility analysis, conducting a MEDLINE search of the postappendectomy wound infection literature to establish assumptions and assign baseline probability estimates. Institution-specific cost data were obtained, and utility assignments were made by the authors. Studies used to assign baseline probabilities fulfilled the following criteria: perforated appendix or gangrenous appendicitis, use of perioperative antibiotics active against aerobic and anaerobic bacteria, and data stratified by wound management, operative findings, and infection rate.
We constructed a decision tree comparing three methods of wound management for contaminated right lower quadrant incisions: primary closure, delayed primary closure, and secondary closure. Utility (a quality of life measure) was assigned to ultimate health states to incorporate patient preference. We calculated the cost-utility for each method of wound management and found that primary closure was of optimum cost-utility compared with delayed primary closure and secondary closure. To gain one quality-adjusted life year treating a population of patients with contaminated incisions, primary closure saves $22,635 over delayed primary closure and another $22,340 over secondary closure. This decision, tested by two-way sensitivity analyses, was sensitive only to high primary closure infection rates.
Challenging traditional surgical dogma, cost-utility analysis shows that primary closure is the favored method of management for contaminated right lower quadrant incisions. This analysis is specific to right lower quadrant incisions and the conclusion is valid for all estimated primary infection rates less than 0.27.
在先前对污染性右下腹切口伤口处理决策的分析中，未考虑患者偏好和治疗成本的影响。
我们进行了一项决策和成本效用分析，对阑尾切除术后伤口感染文献进行了MEDLINE检索，以建立假设并分配基线概率估计值。获取了特定机构的成本数据，并由作者进行效用赋值。用于分配基线概率的研究符合以下标准：阑尾穿孔或坏疽性阑尾炎、使用对需氧菌和厌氧菌有效的围手术期抗生素，以及按伤口处理、手术结果和感染率分层的数据。
我们构建了一个决策树，比较污染性右下腹切口的三种伤口处理方法：一期缝合、二期缝合和延期缝合。将效用（一种生活质量衡量指标）分配给最终健康状态，以纳入患者偏好。我们计算了每种伤口处理方法的成本效用，发现与二期缝合和延期缝合相比，一期缝合具有最佳的成本效用。为了使一群污染切口患者获得一个质量调整生命年，一期缝合比延期缝合节省22,635美元，比二期缝合节省22,340美元。这一决策通过双向敏感性分析进行检验，仅对高一期缝合感染率敏感。
挑战传统外科教条，成本效用分析表明，一期缝合是污染性右下腹切口的首选处理方法。该分析特定于右下腹切口，且对于所有估计的一期感染率小于0.27的情况，结论均有效。
