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

PURPOSE: Decision analysis is a tool that allows clinicians to apply evidence-based medicine to guide objective decisions when faced with uncertain scenarios. Decision analysis in hand surgery has been explored through several studies, but there exists no comprehensive review summarizing the various decision analysis tools utilized. This systematic review aims to appraise and review the different decision analytic models used in hand surgery. METHODS: A search of English articles in 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 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to specific medical indications, with scaphoid fractures (n=6) and carpal tunnel syndrome (n=5) being the most commonly reported. Included papers employed 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 years (QALY) (n=16) and QALY (n=16). The decision analysis models compared and contrasted diagnostic strategies, management options and novel treatments. CONCLUSION: This review demonstrates the increasing popularity of decision analysis in hand surgery. Decision analysis is a useful tool to compare surgical strategies through evaluation of quality of life outcomes and costing data. The most common model was a simple decision tree; scaphoid fractures and CTS were the most common procedures assessed in decision analysis and economic evaluation. Decision analysis models published were of high quality, but could 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.