Decision Tree Sensitivity Analysis Research Articles

Economic modelling of best evidenced podiatry care for the diabetic foot from the South Australian healthcare perspective -a decision tree sensitivity analysis

Economic modelling of best evidenced podiatry care for the diabetic foot from the South Australian healthcare perspective -a decision tree sensitivity analysis

Cost-Benefit of Minimally Invasive Staging of Non-small Cell Lung Cancer: A Decision Tree Sensitivity Analysis

Accurate staging of non-small cell lung cancer (NSCLC) is critical for optimal management. Minimally invasive pathologic assessment of mediastinal lymphadenopathy is increasingly being performed. The cost-benefit (minimization of health care costs) of such approaches, in comparison with traditional surgical methods, is yet to be established. Decision-tree analysis was applied to compare downstream costs of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), conventional TBNA, and surgical mediastinoscopy. Calculations were based on real costs derived from actual patient data at a major teaching hospital in Melbourne, Australia. One- and two-way sensitivity analyses were undertaken to account for potential variation in input parameter values. For the base-case analysis, initial evaluation with EBUS-TBNA (with negative results being surgically confirmed) was the most cost-beneficial approach (AU$2961) in comparison with EBUS-TBNA (negative results not surgically confirmed) ($3344), conventional TBNA ($3754), and mediastinoscopy ($8859). The sensitivity of EBUS-TBNA for detecting disease had the largest impact on cost, whereas the prevalence of mediastinal lymph node metastases determined whether surgical confirmation of negative EBUS-TBNA results remained cost-beneficial. Our study confirms that minimally invasive staging of NSCLC is cost-beneficial in comparison with traditional surgical techniques. EBUS-TBNA was the most cost-beneficial approach for mediastinal staging of patients with NSCLC across all studied parameters.

Nephrectomy‐only for Wilms tumour: Negotiating the tangled web requires multi‐professional input

Nephrectomy‐only for Wilms tumour: Negotiating the tangled web requires multi‐professional input

The Cost-Effective Use of 18F-FDG PET in the Presurgical Evaluation of Medically Refractory Focal Epilepsy

This study applied decision tree analysis to evaluate the sensitivity, specificity, and cost-effectiveness of clinical algorithms that incorporate 18F-FDG PET. A cohort of 176 patients was studied. The localization rate, accuracy, therapeutic impact on the presurgical decision-making process, and correlation with the postsurgical outcome were assessed for the tests commonly performed for seizure localization. Decision tree sensitivity analysis compared 3 imaging strategies with a baseline strategy of medical therapy for all: video-electroencephalography monitoring (VEM)/MRI strategy, in which patients underwent VEM and brain MRI only, and +SPECT and +PET strategies, in which patients with an indeterminate VEM/MRI result underwent ictal SPECT or interictal 18F-FDG PET, respectively. The localization rates for VEM, MRI, 18F-FDG PET, ictal SPECT, and intracranial electroencephalography (EEG) were 62.2%, 35.8%, 75.0%, 60.0%, and 93.8%. The VEM/MRI strategy had the lowest cost per class I/II outcome, but the additional costs per class I/II outcome for the +PET and +SPECT strategies were always below the minimum reported cost savings for a class I/II outcome. There were no valid conditions in which the +SPECT strategy had a lower cost per class I/II outcome than the +PET strategy. Within the range of cost savings estimated to be associated with a class I/II outcome, all decision strategies produced net cost savings; however, these were significantly higher for the +PET and the +SPECT strategies. 18F-FDG PET is cost-effective in the presurgical evaluation, particularly when used in patients with a nonlocalizing or nonconcordant VEM or MRI result.

Cost-Effectiveness Analysis of Antithyroid Drug Therapy, 131I Therapy and Subtotal Thyroidectomy for Graves' Disease

The objective of this study was to assess the cost-effectiveness of antithyroid drug (ATD) therapy vs. radioiodine therapy (RIT) vs. subtotal thyroidectomy (STT) by calculating expected lifelong cost and utility based on Graves' disease patients' responses to questionnaires using a decision-tree sensitivity analysis and relevant variables. The decision-tree sensitivity analysis to determine expected lifelong cost and utility in Graves' disease patients was designed on the basis of the 4 competing strategies consisting of: (1) ATD therapy plus RIT strategy, (2) ATD therapy plus STT strategy, (3) low-fixed-dose (185 MBq) RIT alone strategy, and (4) high-fixed-dose (370 MBq) RIT alone strategy. One-way sensitivity analysis was designed in the ATD therapy plus RIT strategy, for replacement with RIT in place of ATD, ranging from a 100 incidence of ATD side effects to 30%. The low-fixed-dose RIT alone strategy was least costly, and the high-fixed-dose RIT alone strategy most costly. The lifelong utility of high-fixed-dose RIT alone strategy with a 5% rate of discounting was highest (lifelong utility for 30 years : 15.2/patient), and the utility of the ATD plus RIT strategy with 100 side effects of the ATD was lowest (14.1/patient) . The cost-effectiveness ratio was lowest (\5 008/utility) in a low-fixed-dose RIT alone strategy. In conclusion, a low-fixed-dose RIT alone strategy is preferred treatments in view of cost-effectiveness ratio, and RIT should be used more widely in Japan.

Should mediastinoscopy actually be incorporated into the FDG PET strategy for patients with non-small cell lung carcinoma?

Incorporating mediastinoscopy (MS) into the PET-based strategy for non-small cell lung carcinoma (NSCLC) patients might be cost-effective because MS can allow unnecessary thoracotomies to be avoided. The objective of our study was to assess the cost-effectiveness of incorporating MS into a PET strategy for NSCLC patients. To determine life expectancy (LE), quality adjusted life years (QALY), and the incremental cost-effectiveness ratio (ICER), a decision-tree sensitivity analysis was designed for histopathologically confirmed NSCLC patients with M0 disease, based on the three competing strategies of chest CT only vs. PET + CT vs. PET + CT + MS. A simulation of 1000 NSCLC patients was created using baselines of other relevant variables in regard to sensitivity, specificity, mortality, LE, utilities and cost from published data. One-way sensitivity analyses were performed to determine the influences of mediastinal metastasis prevalence on LE, QALY and ICER. The LE and QALY per patient in the CT only strategy, PET + CT strategy and PET + CT + MS strategy were 4.79 and 4.35, 5.33 and 4.93 and 5.68 and 5.33 years, respectively, with a 20% prevalence of mediastinal metastasis. The ICERs were 906.6 yen x 10(3) (7555 US dollars)/QALY/patient at a 20% mediastinal metastasis prevalence, and 2194 yen x 10(3) (18,282 US dollars)/QALY/patient at a 50% prevalence, but exceeded 5280 yen x 10(3) (44,000 US dollars)/QALY/ patient at 80%. Our study quantitatively showed the CT + PET + MS strategy in place of the PET + CT strategy in managing NSCLC patients to be cost-effective. MS should be incorporated into the PET + CT strategy for NSCLC patients except in those highly suspected of having mediastinal disease on chest CT or PET.

Feasibility and cost-effectiveness of sentinel lymph node radiolocalization in stage N0 head and neck cancer.

To determine the feasibility of sentinal lymph node (SN) radiolocalization and to assess the cost-effectiveness of the SN navigation surgery strategy in patients with stage N0 squamous cell carcinoma (SCC) of the head and neck. Patients Eleven consecutive patients with stage N0 SCC of the head and neck. Head and neck lymphoscintigraphy was performed 2 hours after the injection of technetium Tc 99m tin colloid or phytate. A handheld gamma probe was used to detect the SN before and directly after making a skin incision. Nodes were evaluated histopathologically for micrometastasis. To determine the expected cost savings, a decision tree sensitivity analysis was designed based on the 2 competing strategies: ipsilateral neck dissection vs SN navigation surgery. The costs referred to billed costs based on the Japanese national insurance reimbursement system. The sensitivity of SN navigation surgery in our series was 100% (11/11) on a patient-by-patient basis and 94% (17/18) on a node-by-node basis. Micrometastasis was found in 36% (4/11). Assuming the micrometastasis prevalence, sensitivity, and specificity of navigation surgery for detecting SN to be 30%, 90%, and 100%, respectively, the decision tree sensitivity analysis showed that introduction of SN navigation surgery in place of ipsilateral neck dissection would yield cost savings of $1218 (US) per stage N0 patient in Japan and avoid 7 surgical deaths per 1000 patients who are supposed to undergo neck dissection in the neck dissection strategy. Break-even point analysis for the SN navigation surgery strategy showed that the threshold value required more than 41 patients for the savings to begin to accrue. Our results indicate that SN navigation surgery using radiolocalization is feasible and cost-effective, based on decision tree sensitivity analysis, in patients with stage N0 SCC of the head and neck.

A review of the cost-effectiveness of Tc-99m sestamibi scintimammography in diagnosis of breast cancer in Taiwanese women with indeterminate mammographically dense breast

In general, biopsy is the preferred management method for women with indeterminate mammographically dense breasts. In this review, we describe a decision analysis model comparing technetium-99m methoxyisobutylisonitrile (Tc-99m sestamibi) scintimammography and excisional biopsy as breast cancer evaluation strategies for hypothetical cohorts of estimated 16,000–40,000 women with indeterminate mammographic probability of malignancy because of mammographically dense breasts. In cost-effectiveness analysis, quantitative decision tree sensitivity analysis was used to compare the conventional excision biopsy alone strategy (strategy A) with decision strategy for screening with Tc-99m sestamibi scintimammography before excision biopsy (strategy B) after an indeterminate mammogram. Strategy B showed a cost saving of US dollars 649,600–1,624,000 in reducing the cost of unnecessary biopsies. The total cost of strategy B showed a cost saving of US dollars 123,075–307,776 compared to strategy A. The analysis data indicate that Tc-99m sestamibi scintimammography can save the cost of unnecessary biopsies in Taiwanese women with non-diagnostic mammogram because of mammographically dense breasts.

Decision-tree sensitivity analysis for cost-effectiveness of whole-body FDG PET in the management of patients with non-small-cell lung carcinoma in Japan

Whole-body 2-fluoro-2-D-[18F]deoxyglucose [FDG] positron emission tomography (WB-PET) may be more cost-effective than chest PET because WB-PET does not require conventional imaging (CI) for extrathoracic staging. The cost-effectiveness of WB-PET for the management of Japanese patients with non-small-cell lung carcinoma (NSCLC) was assessed. Decision-tree sensitivity analysis was designed, based on the two competing strategies of WB-PET vs. CI. WB-PET was assumed to have a sensitivity and specificity for detecting metastases, of 90% to 100% and CI of 80% to 90%. The prevalences of M1 disease were 34% and 20%. One thousand patients suspected of having NSCLC were simulated in each strategy. We surveyed the relevant literature for the choice of variables. Expected cost saving (CS) and expected life expectancy (LE) for NSCLC patients were calculated. The WB-PET strategy yielded an expected CS of $951 US to $1,493US per patient and an expected LE of minus 0.0246 years to minus 0.0136 years per patient for the 71.4% NSCLC and 34% M1 disease prevalence at our hospital. PET avoided unnecessary bronchoscopies and thoracotomies for incurable and benign diseases. Overall, the CS for each patient was $833US to $2,010US at NSCLC prevalences ranging from 10% to 90%. The LE of the WB-PET strategy was similar to that of the CI strategy. The CS and LE minimally varied in the two situations of 34% and 20% M1 disease prevalence. The introduction of a WB-PET strategy in place of CI for managing NSCLC patients is potentially cost-effective in Japan.

1. Cost-effectiveness of FDG PET for solitary pulmonary nodules: decision tree sensitivity analysis using Australian data

1. Cost-effectiveness of FDG PET for solitary pulmonary nodules: decision tree sensitivity analysis using Australian data

An approach to demonstrating cost-effectiveness of diagnostic imaging modalities in Australia illustrated by positron emission tomography.

The aim of this study was to develop a framework in which the cost-effectiveness of new imaging technologies could be evaluated using data from other countries, while assessing the impact that any differences between the study populations and Australia may have upon the results. Publications reporting the cost-effectiveness or therapeutic impact of positron emission tomography (PET) were re-worked using Australian cost structures. PET was assigned a cost of $950. The effects of potential differences between the populations studied and the Australian population were evaluated by applying sensitivity analysis to those publications that describe decision tree methodology. The parameters included in the sensitivity analysis were disease prevalence and specificity of PET. The Australian cost savings per patient examined by PET were $505.50-$912.41 for investigation of solitary pulmonary nodules, $34.65-$360.03 for lung cancer staging, $550.08 for axillary staging of breast cancer, $230.75-$2301.27 for assessment of recurrent colorectal cancer and $300.24-$2069.65 for assessment of myocardial viability. Significant differences in disease prevalence and PET specificity could occur while the cost-effectiveness of PET was preserved. Decision tree sensitivity analysis can demonstrate the cost-effectiveness of diagnostic imaging modalities in Australia and provides indications that PET is cost-effective for a range of clinical indications.

Decision-Tree Sensitivity Analysis for Cost-Effectiveness of Chest 2-Fluoro-2-D-[18F]Fluorodeoxyglucose Positron Emission Tomography in Patients With Pulmonary Nodules (Non-small Cell Lung Carcinoma) in Japan

Recent studies have demonstrated the potential cost-effectiveness of using 2-fluoro-2-D-[(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) in the management of non-small cell lung carcinoma (NSCLC), but because of differences in health-care systems, those findings may not hold true in a Japanese hospital. To assess the cost-effectiveness of the chest CT plus chest FDG-PET strategy in Japan. Decision-tree sensitivity analysis based on the two competing strategies of chest CT-alone vs chest CT plus chest FDG-PET. A simulation of 1,000 patients in whom NSCLC, stage IIIB or less, was suspected was created using baselines of other relevant variables in regard to sensitivity, specificity, mortality, life expectancy, and cost from published data. We surveyed the relevant literature for the choice of variables. Expected marginal cost and expected life expectancy gain for NSCLC patients. The chest CT plus chest FDG-PET strategy yielded an expected life expectancy gain of 0.607 years (7.3 months) per patient, compared with the alternative strategy of chest CT-alone. Using an FDG-PET examination cost of 1.0 x 10(5) yen (around $700 US) per study, the cost increment was 2.18 x 10(5) yen/yr/patient. The chest CT plus chest FDG-PET strategy in patients with NSCLC is unlikely to be cost-effective in Japan. However, patient life expectancy gain would increase as a result of improved staging of NSCLC. These preliminary results should be confirmed by further studies for specific environments.