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Decision analysis Flashcards

1
Q

Decision Analysis

A

An analytical method for systematically comparing different decision options.
Provides an orderly, analytical approach to assist decision maker in identifying the preferred course of action from among competing alternatives.

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2
Q

When to use decision analysis?

A

When uncertainty about clinical strategy is evident,
When differences in benefits and risk are evident
No head to head trials

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3
Q

Decision analysis characteristics

A

Explicit- forces you to structure the decision you face as well as identify the consequences of the possible outcomes.
Quantitative- Forces you to assign number to probability estimates and outcome valuations.

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4
Q

Applications of decision analysis

A

Choosing among treatments
Choosing between treatment and no treatment
Preventing diseases (vaccinations)
Preventing complications

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5
Q

Decision tree

A

Built to be reflective of clinical reality.

Focuses on most important components, not “real world”

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6
Q

Steps in decision analysis

A
  1. ) Identify decision
  2. ) Specify alternatives
  3. ) Draw tree
  4. ) specify branch, outcomes, probabilities
  5. ) Calculations
  6. ) Conduct a sensitivity analysis
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7
Q

Identifying specifc decision

A

Time period of analysis?
Objective of study?
Perspective?
Example- Decision on whether to add new abx A to an institutional formulary

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8
Q

Specify alternatives

A 
Ideally, compare the most effective treatments
Comparison: 
standard treatment vs. new treatment
Intervention vs. no intervention
More than two competing options.

Example- what should abx A compare to?

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9
Q

What is a choice represented by?

A

Square

Represents conscious decision

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10
Q

What is a chance represented by?

A

Circle
Represents probabilities
It is a chance node

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11
Q

What is terminal (final outcome) represented by?

A

Triangle.

Represents dollars, quality adjusted life years, survival

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12
Q

For each option of decision analysis, what do you need?

A

Probability of occurrence and consequences of occurrence.

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13
Q

Interpretation of a probability of outcome D of 0.126.

A

If 100 people went through the model, about 13 people (12.6) would go down pathway D.

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14
Q

Average cost

A

The cost multiplied by the probability for each terminal node and then added for each option provides the average cost.

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15
Q

Incremental Cost Effectiveness Ratio (ICER)

A

Change in costs/change in outcomes

Example- if 500: 500 more dollars for each additional success with abx a.

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16
Q

Incremental net benefit

A

Alternative to ICER
An estimate for health benefits (outcomes) is added into the incremental analysis (lambda, max willingness to pay, estimated value)
If INB >0, then the intervention is considered cost-effective.

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17
Q

What does it mean if the ICER is positive?

A

One medication is more effective and more costly.

Using a lambda value makes it easier to choose. If the INB value is negative, you lose value.

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18
Q

Sensitivity Analysis

A

Measures the uncertainty in a model
Does not compensate for poor assumptions
The larger the variability, induced by changing a parameter, the more sensitive the outcome is

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19
Q

Overview of Markov modeling

A

Some diseases have complex outcomes that require longer f/u periods (>1 year)
Patients my transition between health states
Each f/u interval is called a cycle

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20
Q

Health states in Markov

A

Must be mutually exclusive. Cannot have the 2 states at the same time. Typically one occurs from complications of another.

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21
Q

Steps in markov modeling

A
  1. ) Choose health states
  2. ) Determine transition states
  3. ) Choose how long and how many cycles
  4. ) Estimate probabilities associated with moving in and out of health states
  5. ) Estimate costs and outcomes.
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22
Q

Absorbing state in markov model

A

Once a pt is in an absorbing state, he/she cannot transition out of it.
Death
Diabetes

You need an absorbing state to finish the model.

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23
Q

Disadvantages of Markov Modeling

A

Complexity and transparency
The Markovian assumption- knowing only the present state of health is sufficient to project the trajectory of future states.

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24
Q

Drug policy is maintained through

A

Formulary system

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25
Formulary
Preferred list of pharmaceuticals to be used in a health system that reflects current clinical judgement.
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Open formulary
Can bring in products not on list. | PBM: Payer will provide coverage for formulary and non-formulary drugs
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Closed formulary
Health system: Limited/no capability to bring in non-approved products PBM: Non-formulary drugs not reimbursed by the payer.
28
Formulary maintenance
P and T committee Voting members- physicians, pharmacists, nurses, health system administrators, respiratory therapists, social workers. Subcommittees may report through P&T
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P&T Activities
``` Formulary drug review FDA drug safety alerts Shortage formulary review Medication use evaluations Drug cost savings initiatives Monitor drug use reports Pharm rep code of conduct enforcement ```
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Formulary categories
Formulary Restricted formulary Non-formulary Non-formulary non-stock
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Formulary category: Formulary
Readily available for use | Provider should order and expect for patient to receive in 1-2 hours
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Formulary category: Restricted formulary
Readily available if certain criteria are met | Drugs may be restricted to disease states, lab values, hospital floors, providers, etc.
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Formulary category: Non-formulary
Not readily available | May be able to order for individual patients if clinical need is demonstrated
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Formulary category: Non-formulary non-stock
Will not be available for use under any circumstances.
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Formulary maintenance decision
Safety data, efficacy data, cost data
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Formulary system support tools
Policy Guidelines restrictions Therapeutic interchanges
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Policies
Dictate how drugs will be ordered, dispensed, administered, monitored, and assessed Should not deviate from policy Can help TJH medication management standards Examples: look-alike sound-alike, vaccine storage, handling, dofetilide use
38
Guidelines
Support evidence-based use of drugs or for disease states May support restrictions May guide administration practices Providers can deviate
39
Restrictions
Criteria that must be met in order to use drug- clinical, provider-based, location-based, financial If outside that criteria is considered non-formulary and may require approval
40
Therapeutic Interchanges
Replace a prescribed drug to another chemically different, clinically similar drug Evidence-based interchange to equivalent doses of preferred agent Streamline inventory Example- PPI
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Formulary assessment process
Request- from providers or pharmacists. Want to know about drug name, clinical reasoning, evidence, estimated volume of use, and conflicts of interest Analysis- Performed by non-biased third party (Drug policy specialist). Assess efficacy, safety, cost data. Recommendation P&T decision- presentation of data, questions from committee members, vote.
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Formulary analysis
Safety data, cost data, efficacy data, other
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Safety, what are we looking at?
``` Contraindications Warnings/precautions AE Post-marketing data Look-alike sound-alike Packaging issues ```
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Efficacy, what are we looking at?
Published information Reviews/expert opinions Guidelines
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Cost, what are we looking at?
Pharmacoeconomic studies if available Cost per unit, per dose, relative to alternatives Volume- based analysis to estimate annual impact Medication access: third party coverage/assistance programs
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Presentation of drug
Pharmacist and other non-biased third party presents drug assessment to P&T or subcommittee
47
Implementation of formulary
``` Electronic medical record changes Dose limitations, order sets, product selection Educate Procurement Storage ```
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Order sets/protocols
Help drive how drugs are used in formulary system | Example: Order set for amphotericin B liposomal that includes pre-hydration and medication
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Procurement
Traditional wholesale Direct purchase Limited distribution
50
White bagging
Can only get through outside specialty pharmacy, sent to hospital
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Brown bagging
Specialty drug dispensed by outside pharmacy and sent to patients home
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Clear bagging
Specialty drug acquired/dispensed by institutions own specialty pharmacy and stored prior to use
53
Quality of life in clinical medicine
Represents the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient
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Measuring HRQoL
Utility measures | Health status measures
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Utility measures
Also referred to as "preference-based measures" or QALY measures Estimates the utility or "value" that individuals assign to different health states Number between 0-1 X length of time in each health state to represent the combined impact on morbidity and mortality in linear fashion Also used to calculate cost-utility Standard gamble and time trade off
56
Health status measures
A patients estimation of their own health at a point in time Measured based off of patients viewpoint Measured in multiple domains; often many scores
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HRQoL Domains
Physical functioning Social and Role Functioning Mental Health General Health perceptions
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Physical functioning
Limitations or disability Physical abilities Days in bed Bodily pain
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Social and Role functioning
Interpersonal contacts- frequency of contacts with family/friends Social resources- social media Are you able to continue doing the things you want to do in life?
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Mental health
Anxiety/depression Psychological well-being Behavioral/emotional control Cognitive function
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General health perceptions
Current self-rating of health | Outlook for future
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General health status instruments
General health | Disease specific
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Generic HRQoL instruments
Relative to any type of situation Advantages- readily available, reliability and validity known, comparable across studies Disadvantages- questions may not be applicable, may not focus on area of interest, may not be sensitive to change
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Disease specific QOL measures
Advantages- tailor made, focuses on question of interest, more likely to detect change Disadvantages- time and effort to design, reliability and validity testing necessary, may not be comprehensive , may not be acceptable to others, cannot cross studies
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QOL tools
Karnofsky functional performance scale EuroQol Instrument Medical Outcomes Study 36-item Short-form health survey
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Karnovsky
Objective measure of functional performance. Completed by healthcare professional with input by patient. Each category is subdivided into 3 descriptors, each associated with a score. The higher the score, the better overall functioning. Categorizes on ability to perform daily activities.
67
EQ-5D
Non-disease specific instrument for measuring of health and health-related qol in patients Self completion by pt Comprises 5 dimensions of health- mobility, self-care, usual activities, pain/discomfort, anxiety and depression Scale is 0-1
68
MOS SF-36
36 questions measuring 8 health attributes Subjective health-realted QOL Self administered Great insight into health of patient
69
SF-36 measurement model
Physical health and mental health broken into 8 total domains
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Psychometrics
The science of using standardized tests or scales to evaluate attributes of an individual Used to translate peoples behavior, feelings, and personal evaluations into quantifiable data Reliability and validity
71
Key factors in selecting HRQOL tool
``` Reliability and validity Responsiveness Acceptability for use Frequency of use Culturally valid ```
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Reliability
Measure is consistent and reproducible Test-retest reliability Internal consistency Intra and inter observer reliability
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Validity
Does the questionnaire really measure QOL?
74
Responsiveness
Do scores accurately reflect over time?
75
What is most widely used QOL tool?
SF-36 | In many languages, culturally tested
76
What is the use of QOL in clinical trials and practice?
Very important to look at whole patient.

Evidence Based Pharmacotherapy (3 decks)

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