Doctors at Risk: A Problem As Viewed by Decision Analysis

The authors closely analyze a case in which a Peer Review Organization cited a physician for treatment with potential for significant adverse effect. They also critique the regulatory scheme under which peer review occurs and conclude that such regulation interferes with physicians\u27 primary obligations, fails to encourage cost-effective behavior and may decrease the quality of medical care

Comparative Analysis of Cervical Spine Management in a Subset of Severe Traumatic Brain Injury Cases Using Computer Simulation

BACKGROUND: No randomized control trial to date has studied the use of cervical spine management strategies in cases of severe traumatic brain injury (TBI) at risk for cervical spine instability solely due to damaged ligaments. A computer algorithm is used to decide between four cervical spine management strategies. A model assumption is that the emergency room evaluation shows no spinal deficit and a computerized tomogram of the cervical spine excludes the possibility of fracture of cervical vertebrae. The study's goal is to determine cervical spine management strategies that maximize brain injury functional survival while minimizing quadriplegia. METHODS/FINDINGS: The severity of TBI is categorized as unstable, high risk and stable based on intracranial hypertension, hypoxemia, hypotension, early ventilator associated pneumonia, admission Glasgow Coma Scale (GCS) and age. Complications resulting from cervical spine management are simulated using three decision trees. Each case starts with an amount of primary and secondary brain injury and ends as a functional survivor, severely brain injured, quadriplegic or dead. Cervical spine instability is studied with one-way and two-way sensitivity analyses providing rankings of cervical spine management strategies for probabilities of management complications based on QALYs. Early collar removal received more QALYs than the alternative strategies in most arrangements of these comparisons. A limitation of the model is the absence of testing against an independent data set. CONCLUSIONS: When clinical logic and components of cervical spine management are systematically altered, changes that improve health outcomes are identified. In the absence of controlled clinical studies, the results of this comparative computer assessment show that early collar removal is preferred over a wide range of realistic inputs for this subset of traumatic brain injury. Future research is needed on identifying factors in projecting awakening from coma and the role of delirium in these cases

A method for evaluating breast cancer screening strategies using screen-preventable loss of life.

The objective of this study is to describe how screen-preventable loss of life (screen-PLL) can be used to analyze the distribution of life savings with mammographic screening. The determination of screen-PLL with mammography is possible using a natural history model of breast cancer that simulates clinical and pathologic events of this disease. This investigation uses a Monte Carlo Markov model with data from the Surveillance, Epidemiology, and End Results Program; American Cancer Society; and National Vital Statistics System. Populations of one million women per screening strategy are simulated over a lifetime with mammographic screening based on current guidelines of the American Cancer Society (ACS), United States Preventive Services Task Force (USPSTF), triennial screening from age 50-70, and no screening. Screen-PLL curves are generated and show guideline performance over a lifetime. The screen-PLL curve with no screening is determined by tumor discovery through clinical awareness and has the highest values of screen-PLL. The ACS and USPSTF strategies demonstrate screen-PLL curves favoring the elderly. The curve for triennial screening is more uniform than the ACS or USPSTF curves but could be improved by adding screen(s) at either end of the 50-70 age range. This study introduces the use of screen-PLL as a tool to improve the understanding of screening guidelines and allowing a more balanced allocation of life savings across an aging population. The method presented shows how screen-PLL can be used to analyze and potentially improve breast cancer screening guidelines

Expected Clinical Outcomes per 1,000 and QALYs By CSM Strategy and Patient Category with 2.5% Probability of Cervical Spine Instability.

<p>FS is Functional Survival</p><p>Quad is Quadriplegic</p><p>SBD is Severe Brain Disability</p><p>QALYs are Quality Adjusted Life Years</p><p>US for Unstable, HR for High Risk and S for Stable</p><p>LCR is Late Collar Removal</p><p>ECR is Early Collar Removal</p><p>*Totals of clinical outcomes may vary by one due to rounding</p

Collar complications expressed as marginal probability^*in percent according to categories of TBI.

<p>*Difference in occurrences of late and early collar removal.</p><p>US for Unstable, HR for High Risk and S for Stable</p><p>IICP is increased intracranial pressure</p><p>VAP is ventilator associated pneumonia</p

QALYs Resulting from Quadriplegia and CS Management Complications with a 5.0% Probability of Cervical Spine Instability in the Stable category of TBI.

<p>TBI is Traumatic Brain Injury</p><p>QALYs are Quality Adjusted Life Years</p><p>LCR is Late Collar Removal</p><p>ECR is Early Collar Removal</p><p>Quad is Quadriplegia</p><p>CSM BI is Cervical Spine Management Brain Injury</p><p>NA is not applicable</p

QALYs Resulting from Quadriplegia and CS Management Complications with a 2.5% Probability of Cervical Spine Instability in the categories of TBI.

<p>TBI is Traumatic Brain Injury</p><p>QALYs are Quality Adjusted Life Years</p><p>LCR is Late Collar Removal</p><p>ECR is Early Collar Removal</p><p>Quad is Quadriplegia</p><p>CSM BI is Cervical Spine Management Brain Injury</p><p>NA is not applicable</p