Decision Analysis Study Research Articles

Multi-Criteria Decision Analysis for Sustainable Oil and Gas Infrastructure Decommissioning: A Systematic Review of Criteria Involved in the Process

The decommissioning of oil and gas (O&G, hereafter) facilities presents complex challenges when addressing the diverse needs of stakeholders. By synthesizing information from previous Multi-Criteria Decision Analysis (MCDA, hereafter) studies on decommissioning projects, this study aims to do the following: (a) formulate a structured set of criteria adaptable to MCDA for both offshore and onshore O&G decommissioning, (b) identify and analyze the evolving trends and regional disparities in MCDA for decommissioning, and (c) explore current O&G onshore decommissioning procedures and map specific criteria to these processes. Following a systematic literature review approach, this study analyzed 63 references across four stages from 2006 to 2024 and identified 158 criteria. These criteria were consolidated into a framework of 22 factors across dimensions comprising technical, environmental, societal, financial, health and safety considerations, and additional concerns from stakeholders. This study observed a significant focus shift from technical aspects to environmental considerations in decommissioning practices from 2011 onwards, reflecting growing awareness of sustainability. It also revealed regional differences, such as the technical emphasis in the North Sea and environmental concerns in Australia. Furthermore, this study refined O&G onshore decommissioning procedures and identified criteria gaps for further research, particularly in societal impact regarding public resource availability, recreational opportunities, and operating company reputation. The study provides a robust foundation for the development of future MCDA frameworks tailored to O&G infrastructure decommissioning projects, thus supporting long-term environmental and social sustainability.

Multi-criteria decision analysis and experimental study on heat pipe thermoelectric generator for waste heat recovery

In the realm of heat conversion and utilization, gravity heat pipes have garnered significant attention due to their exceptional heat conduction efficiency. As a strategy to effectively enhance the efficiency of thermoelectric generator (TEG) systems through shallow geothermal heat recovery, optimizing the performance of gravity heat pipes holds significant implications for their widespread application in the field of sustainable energy. Experimental evaluations comprehensively assessed the performance of a 6 m gravity heat pipe within a temperature difference power generation system, employing multi-criteria decision-making to test thermal performance, efficiency, reliability, stability, and working fluid studies. The study demonstrates that the heat transfer efficiency of gravity heat pipes is highest under film boiling conditions at 250 °C to 350 °C. By adjusting the inclination angle to 60° to 90° and the filling ratio to 30 %–60 %, the power generation efficiency can be improved to 9.71 %. With an increase in wind speed to 8 m/s, the cold end temperature decreases by 30 %, resulting in a peak power generation efficiency of up to 11.3 %. Additionally, CHIME connection methods reduce energy losses to 8.1 %, providing crucial scientific foundations for the design and optimization of temperature difference power generation systems. These findings not only elucidate the heat transfer mechanisms of gravity heat pipes but also offer technical guidance for efficient energy conversion in thermoelectric generator systems.

696 Optimal Management Strategy for Carotid Cavernous Aneurysm From Cost-effectiveness Perspective

INTRODUCTION: Most cavernous carotid aneurysms (CCAs) are asymptomatic benign lesions; therefore, they are frequently detected during routine clinical diagnostic processes. Most providers recommend routine surveillance instead of immediate management for CCAs given a natural history with a low risk of life-threatening complications. However, the cost-effectiveness of such care and the optimal follow-up interval remains unknown. METHODS: A decision analysis study was performed utilizing a Markov model with Monte Carlo simulations to simulate patients undergoing treatment or routine surveillance at different time intervals (half, 1-,2-,3-, 5-and 7-year intervals) for different size of CCAs (=<12 mm, 13- 24 mm, >=25 mm ). Input data for the model was extracted from the current literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the Model. RESULTS: On base case analysis, following-up every 2 years with noninvasive imaging is the most cost-effective strategy for CCAs =< 12 mm, while annual follow up is cost-effective for large/giant (13-24 mm, >=25 mm) CCAs. The conclusions remain robust in probabilistic sensitivity and deterministic sensitivity analyses. As the risk of thrombo-embolic event gets higher and annual growth risk and annual rupture risk of CCAs increases, immediate treatment for large/giant (13- 24 mm, >=25 mm ) CCAs and annual follow up even prompt treatment for CCAs =< 12 mm is optimal. CONCLUSIONS: The most cost-effective management strategy for CCAs=< 12 mm and large/giant CCAs are following up every 2 years and following up every year, respectively. More frequent follow-up strategies or prompt preventive treatment for CCAs =< 12 mm and immediate treatment for large/giant CCAs would be more appropriate in patients with higher risk factors for cerebral ischemia, aneurysm growth and aneurysm rupture.

Methods of Analyzing Judges' Decisions in Normative Legal Research Case-based Approach and Islamic Law

This study aims to examine how decision analysis studies should be conducted. In addition to examining the case approach in normative legal research, which is a commonly used approach in decision analysis studies, this study was also conducted to investigate the methods and characteristics of decision analysis. Using qualitative and document research methods, data was collected through focus group discussions and documentation. This study found that decision analysis research is specifically a case-specific study, possibly using philosophical and conceptual approaches simultaneously. The steps of decision analysis research also specifically follow the IRAC (Issue, Rule, Attention and Conclusion) method. This study is expected to contribute to the development of the discourse on legal research methodology with its various approaches, especially approaches that have been introduced in normative legal research. Practically, this study is expected to provide guidance for students to conduct normative legal research with a case approach, especially in decision analysis research. The results of this study are also expected to be a guide for supervisors to guide students who conduct normative legal research with a case approach, especially research on the analysis of judges' decisions.

Cost-effectiveness of latent tuberculosis infection testing and treatment with 6-week regimen among key population in rural communities in China: a decision analysis study.

Several model studies suggested the implementation of latent tuberculosis infection (LTBI) testing and treatment could greatly reduce the incidence of tuberculosis (TB) and achieve the 2035 target of the "End TB" Strategy in China. The present study aimed to evaluate the cost-effectiveness of LTBI testing and TB preventive treatment among key population (≥ 50 years old) susceptible to TB at community level in China. A Markov model was developed to investigate the cost-effectiveness of LTBI testing using interferon gamma release assay (IGRA) and subsequent treatment with 6-month daily isoniazid regimen (6H) (as a standard regimen for comparison) or 6-week twice-weekly rifapentine and isoniazid regimen (6-week H2P2) in a cohort of 10,000 adults with an average initial age of 50 years. In the base-case analysis, LTBI testing and treatment with 6H was dominated (i.e., more expensive with a lower quality-adjusted life year (QALY)) by LTBI testing and treatment with 6-week H2P2. LTBI testing and treatment with 6-week H2P2 was more effective than no intervention at a cost of $20,943.81 per QALY gained, which was below the willingness-to-pay (WTP) threshold of $24,211.84 per QALY gained in China. The one-way sensitivity analysis showed the change of LTBI prevalence was the parameter that most influenced the results of the incremental cost-effectiveness ratios (ICERs). As estimated by a Markov model, LTBI testing and treatment with 6-week H2P2 was cost-saving compared with LTBI testing and treatment with 6H, and it was considered to be a cost-effective option for TB control in rural China.

Groundwater delineation for sustainable improvement and development aided by GIS, AHP, and MIF techniques

Exploration of groundwater is an integral part of viable resource growth for society, economy, and irrigation. However, uncontrolled utilization is mainly reported in urban and industries due to the increasing demand for water in semi-arid and arid regions of the world. In the background, groundwater demarcation for potential areas is vital in meeting necessary demand. The current study applied an integrated method comprising the analytical hierarchy process (AHP), multiple influence factors (MIF), combined with a linear regression curve and observatory well data for groundwater prospects mapping. Thematic maps such as flow direction, flow accumulation, elevation map, land use land cover, slope, soil texture, hill shade, geomorphology, normalized vegetation index, and groundwater depth map were generated utilizing remote sensing techniques. The relative weight of each parameter was estimated and then assigned to major and minor parameters. Potential zones for groundwater were classified into five classes, namely very good, good, moderate, poor, and very poor, based on AHP and MIF methods. A spatially explicit sensitivity and uncertainty analysis method to a GIS-based multi-criteria groundwater potential zone model is presented in this research. The study addressed a flaw in the way groundwater potential mapping results are typically presented in GIS-based multi-criteria decision analysis studies, where discrete class outputs are used without any assessment of their certainty with respect to variations in criteria weighting, which is one of the main contributors to output uncertainty. The study region is categorized based on inferred results as very poor, poor, marginal, and very good in potential ground quality 3.04 km2 is considered extremely poor, 3.33 km2 is considered poor, 64.42 km2 is considered very good, and 85.84 km2 is considered marginal zones, which shows reliable and potential implementation. The outcomes of AHP and MIF were validated by linear regression curve and actual water table in a study area. The study results help to formulate the potential demarcation of groundwater zones for future sustainable planning and development of groundwater sources. This study may be helpful to provide a cost-effective solution to water resources crises. The current study finding may be helpful for decision-makers and administrative professionals for sustainable management of groundwater resources for present and future demands.

Impact of collateral flow on cost-effectiveness of endovascular thrombectomy.

Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals. A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed. EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0-2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%-8% more patients than medical management. EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.

Cost-effectiveness analysis on small (< 5 mm) unruptured intracranial aneurysm follow-up strategies.

Unruptured intracranial aneurysms are frequently detected during routine clinical diagnostic processes. A significant portion are small aneurysms less than 5 mm in diameter. While follow-up of patients with small aneurysms has been advocated, the cost-effectiveness of such care and the optimal follow-up interval remain unknown. This study aimed to explore the most cost-effective follow-up interval for small (< 5 mm) unruptured intracranial aneurysms. A decision analysis study was performed using a Markov model with Monte Carlo simulations to simulate patients undergoing follow-up by MRA at different time intervals (1-, 2-, 3-, 5-, and 7-year intervals) for small (< 5 mm) unruptured intracranial aneurysms. Input data for the model were extracted from the current literature, primarily meta-analyses. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model. Given the current literature and the model in this study, following up every 2 years with noninvasive imaging is the most cost-effective strategy (cost $126,996, effectiveness 21.9 quality-adjusted life-years), showing the highest net monetary benefit. The conclusion remains robust in probabilistic and deterministic sensitivity analyses. As the annual growth risk of small aneurysms and annual rupture risk of growing aneurysms increase, following up every year is optimal. When the cost for follow-up with MRA is less than $2223, following up every year is cost-effective. The most cost-effective follow-up strategy for small (< 5 mm) unruptured aneurysms using MRA is following up every 2 years. More frequent follow-up strategies or prompt preventive treatment would be more appropriate in patients with higher risk factors for growth and aneurysm rupture.

Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction

Background: Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. Purpose: To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients’ out-of-pocket expenditures? (2) How are reimbursements from payers and patients’ out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? Study Design: Economic and decision analysis study; Level of evidence, 4. Methods: A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. Results: Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. Conclusion: Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Integrating spatially explicit sensitivity and uncertainty analysis in a multi-criteria decision analysis-based groundwater potential zone model

This study presents a spatially explicit sensitivity and uncertainty analysis approach to a GIS-based multi-criteria groundwater potential zone model. The study addressed a deficiency in the way groundwater potential mapping results are typically presented using discrete class outputs without assessment of their certainty with respect to variations in criteria weighting, one of the main contributors to output uncertainty in GIS-based multi-criteria decision analysis studies. We argue, moderating groundwater potential mapping results with localised uncertainty levels will help to refine and prioritise groundwater exploration efforts. The approach also enables a better understanding of the underlying factors influencing uncertainty in model outputs, which can help to inform the calibration of input parameters to improve model performance. Although the procedures presented in this study have been applied to other types of multi-criteria evaluations, its integration in GIS-based groundwater potential modelling has received little attention. We provide a case study focused on a fractured rock environment surrounding the township of Hawker in South Australia where new groundwater resources are sought. Small incremental weight changes were applied one-at-a-time and automated as a task in ArcGIS Pro, built using the ArcPy Python module that interacts with spatial tools allowing geographical analysis. The approach is applicable to both continuous and discrete class-based mapping outputs and enabled a deeper understanding of model output behaviour with respect to criteria weighting alternatives. The case study findings demonstrate the potential value of the approach in mitigating uncertainty and improving confidence in locating sites with high groundwater potential.

402 Cost-Effectiveness Analysis on Small (&lt;5 mm) Unruptured Intracranial Aneurysm Follow-up Strategies

INTRODUCTION: Unruptured intracranial aneurysms are frequently detected during routine clinical diagnostic processes. A significant portion is small aneurysms less than 5mm. While follow-up patients with small aneurysms have been advocated, the cost-effectiveness of such care and the optimal follow-up interval remain unknown. METHODS: A decision analysis study was performed utilizing a Markov model with Monte Carlo simulations to simulate patients undergoing follow-up by MRA at different time intervals (1-,2-,3-, 5-and 7-year intervals) for small (&lt;5mm) unruptured intracranial aneurysms. Input data for the model was extracted from the current literature, primarily latest Meta-analysis. Probabilistic sensitivity analysis and deterministic sensitivity analyses were performed to evaluate the robustness of the Model. RESULTS: Given current literature and our model, following-up every 3 years with noninvasive imaging is the most cost-effective strategy (cost = $99611, effectiveness = 19.00 QALYs), showing the highest net monetary benefit. The conclusion remains robust in probabilistic sensitivity analysis and deterministic sensitivity analyses. As the annual rupture risk of small aneurysms exceeds 9.8% (base-case 3.1%), following up every 2 years becomes the optimal strategy. CONCLUSION: The most cost-effectiveness follow-up strategy for small (&lt;5mm) unruptured aneurysms using MRA is follow-up every 3 years. More frequent follow-up strategies or prompt preventive treatment would be more appropriate in patients with a higher rupture risk of growing aneurysms.

Priority setting of vaccine introduction in Bangladesh: a multicriteria decision analysis study

ObjectiveTo prioritise vaccines for introduction in Bangladesh.MethodsMulticriteria decision analysis (MCDA) process was used to prioritise potential vaccines for introduction in Bangladesh. A set of criteria were identified, weighted and assigned...

Evaluation of pharmaceutical intervention strategies against pandemics in Sweden: A scenario‐driven multiple criteria decision analysis study

AbstractTo enhance preparedness for diverse pandemic situations we aim to predict the performance of various pharmaceutical intervention strategies. We gathered domain experts and ran a series of decision conferences where a scenario‐based multi‐criteria decision analysis (MCDA) model was interactively defined and implemented. Assuming an influenza pandemic, a micro simulation model was used to estimate societal health impact, a health‐economic model was used to estimate economic losses, and expert preferences were elicited to define trade‐offs between multiple criteria and synthesize various estimates. Sensitivity analysis to address various forms of uncertainty was also conducted. Nine intervention strategies, including the baseline “no interventions” strategy, were evaluated and ranked under five pandemic scenarios for Sweden's population. We conclude that a scenario‐based MCDA approach relying on multiple models for assessment of consequences is instrumental in defining robust interventions and support decision‐making at the pre‐pandemic and pandemic situations.

Planning, design and logistics of a decision analysis study: The FBI/Ames study involving forensic firearms examiners

This paper describes design and logistical aspects of a decision analysis study to assess the performance of qualified firearms examiners working in accredited laboratories in the United States in terms of accuracy (error rate), repeatability, and reproducibility of decisions involving comparisons of fired bullets and cartridge cases. The purpose of the study was to validate current practice of the forensic discipline of firearms/toolmarks (F/T) examination. It elicited error rate data by counting the number of false positive and false negative conclusions. Preceded by the experimental design, decisions, and logistics described herein, testing was ultimately administered 173 qualified, practicing F/T examiners in public and private crime laboratories. The first round of testing evaluated accuracy, while two subsequent rounds evaluated repeatability and reproducibility of examiner conclusions. This project expands on previous studies by involving many F/T examiners in challenging comparisons and by executing the study in the recommended double-blind format.

SP5.1.12 Discrete Event Micro Simulation Modeling for the Treatment of Resectable Malignancy of the Oesophagus and Gastrooesophageal Junction

Abstract Aims To assist decision-making by creation of a statistical model that simulates treatment pathways and subsequent outcomes for the management of resectable malignancy of the oesophagus and gastrooesophageal junction. Methods: Discrete Event Simulation (DES) modelling is a statistical modelling technique that models the operation of a system as a sequence of events in time to support decision-making. This approach lends itself well to disease modelling by incorporating different treatment strategies targeted at different groups. It offers an advantage over previous decision analysis studies that have relied on Markov modelling which can have reduced accuracy due to lack of memory within the Markov model, the effect of depletion of susceptibles, and the timing of transitioning within the model. This simulation model was populated with data from best available evidence from contemporary randomised controlled trials and ran over 100,000 iterations. Results Neoadjuvant chemoradiotherapy was the superior treatment pathway with superior pathway selection frequency of 87.16%. For squamous cell carcinoma neoadjuvant chemoradiotherapy was the superior treatment option with 73.30 months survival time (65.60 QALMs) and had a superior pathway selection frequency of 100%. Conclusions DES simulation modeling for decision analysis in treatment of resectable malignancy of the oesophagus and gastrooesophageal junction supports the use of neoadjuvant chemoradiotherapy.

Karar Teorisinin Tarım Sektöründe Uygulanması

Karar analizi, karşılaşılan problemleri dikkate alarak çeşitli ölçütler sunmakta ve değerlendirme fırsatı sağlamaktadır. Tarım sektöründe karşılaşılacak problemlerin belirsizlik ve risk taşıması karar analizinin sektörde kullanılmasını sağlamıştır. Bu çalışmada Tekirdağ’ın Şarköy ilçesinde tarım işleri ile uğraşan çiftçinin arazisinde yapacağı faaliyete karar verme aşamasında karar analizi çalışması yapılmıştır. Çalışmada yer alan durumlar belirsizlik ve risk altında değerlendirilmiş ve karar ağacı çizilerek sonuçlar yorumlanmıştır. Çalışmanın amacı çiftçiye belirlenen karar durumlarına bağlı olarak uygun olan seçeneği sunmak ve karar analizini tarım sektöründe uygulamaktır. Araştırma için gerekli bilgilere konu ile ilgili bilgi sahibi kişi ile yapılan görüşme yoluyla ulaşılmıştır. Ulaşılan verilerin analizi sonucunda belirsizlik ve risk altında değerlendirilmiştir. Veriler aracılığı ile çizilen karar ağacında olasılıklar iki farklı yol ile bulunmuştur. Karar ağacında olasılıkların atanma yolu değişmesine rağmen her iki durumda da seçilmesi uygun olan faaliyetin zeytin olduğuna karar verilmiştir.

Prioritisation for future surveillance, prevention and control of 98 communicable diseases in Belgium: a 2018 multi-criteria decision analysis study

BackgroundNational public health agencies are required to prioritise infectious diseases for prevention and control. We applied the prioritisation method recommended by the European Centre for Disease Prevention and Control to rank infectious diseases, according to their relative importance for surveillance and public health, to inform future public health action in Belgium.MethodsWe applied the multi-criteria-decision-analysis approach. A working group of epidemiologists and statisticians from Belgium (n = 6) designed a balanced set of prioritisation criteria. A panel of Belgian experts (n = 80) allocated in an online survey each criteria a weight, according to perceived relative importance. Next, experts (n = 37) scored each disease against each criteria in an online survey, guided by disease-specific factsheets referring the period 2010–2016 in Belgium. The weighted sum of the criteria’s scores composed the final weighted score per disease, on which the ranking was based. Sensitivity analyses quantified the impact of eight alternative analysis scenarios on the top-20 ranked diseases. We identified criteria and diseases associated with data-gaps as those with the highest number of blank answers in the scoring survey. Principle components of the final weighted score were identified.ResultsWorking groups selected 98 diseases and 18 criteria, structured in five criteria groups. The diseases ranked highest were (in order) pertussis, human immunodeficiency virus infection, hepatitis C and hepatitis B. Among the five criteria groups, overall the highest weights were assigned to ‘impact on the patient’, followed by ‘impact on public health’, while different perceptions were identified between clinicians, microbiologists and epidemiologists. Among the 18 individual criteria, ‘spreading potential’ and ‘events requiring public health action’ were assigned the highest weights. Principle components clustered with thematic disease groups. Notable data gaps were found among hospital-related diseases.ConclusionsWe ranked infectious diseases using a standardised reproducible approach. The diseases ranked highest are included in current public health programs, but additional reflection for example about needs among risk groups is recommended. Cross-reference of the obtained ranking with current programs is needed to verify whether resources and activities map priority areas. We recommend to implement this method in a recurrent evaluation cycle of national public health priorities.

Trends in Use and Timing of Intratympanic Corticosteroid Injections for Sudden Sensorineural Hearing Loss.

Oral corticosteroids are treatment mainstays for idiopathic sudden sensorineural hearing loss (SSNHL). Recent studies suggest that intratympanic (IT) steroid injections may be effective as an alternate or adjunctive therapy. We sought to investigate nationwide trends in treatment patterns for SSNHL. Retrospective cross-sectional study. A large nationwide health care claims database spanning 2007 to 2016. Patients with SSNHL were identified from the IBM Watson Health MarketScan Database. Multivariable logistic, linear, and Cox regression were used for demographic- and comorbidity-adjusted analyses. Overall, 19,670 patients were included. Between 2007 and 2016, use of oral corticosteroids alone decreased (83.6% to 64.6%, P < .001), while use of IT corticosteroids alone and combination IT-oral corticosteroids increased (IT only, 7.9% to 15.1%, P = .002; IT-oral, 8.5% to 20.4%, P < .001). During the study period, time to treatment initiation decreased for both administration modalities, though more dramatically for IT corticosteroids (IT, 124.0 to 10.6 days, P < .001; oral, 42.6 to 12.7 days, P < .001). In patients receiving both IT and oral corticosteroids, concurrent first-line use increased (25.2% to 52.8%, P < .001). Repeat injections have also become more common but may raise risk of persistent tympanic membrane perforations (vs no injection; hazard ratio [first injection] = 7.95, 95% CI = 5.54-11.42; hazard ratio [fifth or higher injection] = 17.47, 95% CI = 6.93-44.05). SSNHL management increasingly involves early IT steroids as an alternative or adjunctive option to oral steroids. Use of repeat IT corticosteroid injections has also increased but may raise risk of persistent tympanic membrane perforations and subsequent tympanoplasty. Future decision analysis and cost-effectiveness studies are necessary to identify an optimal care pattern for SSNHL.

Markov models in cardiac surgery.

Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.

Prospective Decision Analysis Study of Clinical Genomic Testing in Metastatic Breast Cancer: Impact on Outcomes and Patient Perceptions.

To evaluate the impact of targeted DNA sequencing on selection of cancer therapy for patients with metastatic breast cancer (MBC). In this prospective, single-center, single-arm trial, patients with MBC were enrolled within 10 weeks of starting a new therapy. At enrollment, tumor samples underwent next-generation sequencing for any of 315 cancer-related genes to high depth (> 500×) using FoundationOne CDx. Sequencing results were released to providers at the time of disease progression, and physician treatment recommendations were assessed via questionnaire. We evaluated three prespecified questions to assess patients' perceptions of genomic testing. In all, 100 patients underwent genomic testing, with a median of five mutations (range, 0 to 13 mutations) detected per patient. Genomic testing revealed one or more potential therapies in 98% of patients (98 of 100), and 60% of patients (60 of 100) had one or more recommended treatments with level I/II evidence for actionability. Among the 94 genomic text reports that were released, there was physician questionnaire data for 87 patients (response rate, 92.6%) and 31.0% of patients (27 of 87) had treatment change recommended by their physician. Of these, 37.0% (10 of 27) received the treatment supported by genomic testing. We did not detect a statistically significant difference in time-to-treatment failure (log-rank P = .87) or overall survival (P = .71) among patients who had treatment change supported by genomic testing versus those who had no treatment change. For patients who completed surveys before and after genomic testing, there was a significant decrease in confidence of treatment success, specifically among patients who did not have treatment change supported by genomic testing (McNemar's test of agreement P = .001). In this prospective study, genomic profiling of tumors in patients with MBC frequently identified potential treatments and resulted in treatment change in a minority of patients. Patients whose therapy was not changed on the basis of genomic testing seemed to have a decrease in confidence of treatment success.