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Venous stasis ulcers present a challenge to healthcare providers as they are chronic, recurrent, affect the quality of life of individuals and significantly impact the costs and utilization of healthcare resources. Use of evidence-based approaches alone without consideration of diagnostic and therapeutic uncertainties, patient preferences, values and costs may lead to decisions that may have substantial consequences, trade-offs and poor outcomes as defined by the clinician and patient.
Purpose: To develop a decision making model that requires clinicians to examine and explore assumptions, values, preferences and evidence in decision making related to the use of compression in venous stasis ulcer management.
Objective: To apply the framework provided by the PROACTIVE model to develop a decision analysis model that integrates evidence and values: Specifically define the problem, reframe the problem from multiple perspectives, focus on objectives, expand alternatives, estimate consequences, explicitly make trade-offs, integrate the evidence and values, optimize the expected values and explore assumptions and uncertainty.
Outcomes: To determine the cost associated with assumptions regarding: treatment alternatives (high compression – Likelihood of use 60% vs. low compression – Likelihood of use 40%, evidence and anecdotal evidence) vs. no treatment (worsening of ulcer, malpractice: Value $500,000); Presence of arterial insufficiency 30% (evidence based); probability of wound healing vs. wound complications/delayed healing (both evidence and anecdotal experience); cost of high compression for episode of care (evidence = $2020) vs. low compression (evidence = $3222).
Conclusion: Assumptions, values and outcome preferences can be built into a predictive model that enables the clinician to objectively evaluate data and make decisions in complex cases. These analyses may be tailored to assist with the education of patients related to decisions and outcomes.