Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review.

BACKGROUND: Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery. METHODS: A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article. RESULTS: The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments. CONCLUSIONS: Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.