Análise de decisão multicritério - MCDA - em hospital terciário: prevenção de trombose venosa profunda em cirurgias ortopédicas de grande porte
Análise de decisão multicritério - MCDA - em hospital terciário: prevenção de trombose venosa profunda em cirurgias ortopédicas de grande porte
Arquivos
Data
2017
Autores
Morais, Quenia Cristina Dias
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
A artroplastia total de joelho e artroplastia total de quadril são cirurgias ortopédicas de grande porte que apresentam risco de complicações cirúrgicas e clínicas, das quais a mais prevalente é a trombose venosa profunda. Sem a realização de profilaxia, estudos estimam que a incidência de trombose venosa profunda varia entre 40 e 60%. O uso de anticoagulantes é recomendado por diretrizes internacionais para evitar essa complicação. Existem no mercado diversos anticoagulantes orais e injetáveis, na prática o uso pode variar entre as instituições e de acordo com a preferência do médico. A Enoxaparina é o anticoagulante mais usado no Instituto Nacional de Traumatologia e Ortopedia. Comparada a ela, os anticoagulantes orais podem oferecer maior conforto, com eficácia semelhante ou superior, porém, com mais risco de sangramento, caracterizando um cenário que envolve incertezas e riscos, implicando na necessidade de fazer escolhas em situações onde múltiplos grupos podem sofrer os impactos dessa decisão em longo prazo. Os decisores quando chegam a uma resolução racional sem suporte, tendem a usar abordagens heurísticas ou intuitivas para tomar a decisão mais simples e, no processo, informações importantes podem ser ignoradas. Nesse contexto, ao considerar múltiplos critérios, simultaneamente, além das incertezas associadas a cada escolha com gerenciamento da discordância entre os decisores, o processo se torna mais transparente e robusto. A Análise de Decisão Multicritérios - MCDA é um conjunto de métodos, e nessa perspectiva, foi discutida a escolha do anticoagulante de maior valor na preferência dos decisores. Esse estudo teve como objetivo primário desenvolver uma estrutura conceitual (Framework) de MCDA com o método MACBETH para avaliar dois anticoagulantes, Rivaroxabana e Enoxaparina e testar em um contexto hospitalar de prevenção de trombose venosa profunda no pós-operatório de artroplastia de joelho e quadril. Os critérios e as alternativas foram selecionados em entrevista com as partes interessadas. O desempenho foi estimado por revisão rápida da literatura e metanálise dos ensaios clínicos. O modelo, incluindo os pesos, foi elaborado em uma conferência de decisão, onde ocorreu o julgamento qualitativo das preferências de forma consensual. Foi realizada análise de sensibilidade e robustez após a conferência de decisão. Rivaroxabana foi o anticoagulante de maior valor para o cenário de profilaxia da TVP, e os critérios de maior importância na opinião dos decisores foram: “Morte por qualquer causa”, “Sangramento clinicamente importante” e “Prevenção de trombose venosa profunda proximal”. O Custo total do tratamento não interferiu nos resultados do modelo. O uso bem-sucedido do método MACBETH, com a realização de uma conferência de decisores em um hospital terciário, valida o seu uso como uma ferramenta de suporte à gestão auxiliando na tomada de decisões transparentes, robustas e defensáveis diante dos mais diferentes problemas complexos que o cenário hospitalar enfrenta.
Total knee replacement and total hip replacement are large orthopedic surgeries that present a risk of surgical and clinical complications, of which the most prevalent is deep vein thrombosis. Without prophylaxis, the incidence of deep venous thrombosis varies between 40 and 60%. The use of anticoagulants is recommended by international guidelines to avoid this complication. There are several oral and injectable anticoagulants on the market, in practice the use may vary between institutions and according to the preference of the physician. Enoxaparin is the most commonly used anticoagulant in the National Institute of Traumatology and Orthopedics. Compared with it, oral anticoagulants can offer greater comfort, with similar or superior efficacy, but with a higher risk of bleeding, characterizing a scenario that involves uncertainties and risks, implying the need to make choices in situations where multiple groups can suffer the impacts long-term decision. Decision makers, when arriving at a rational resolution without support, tend to use heuristic or intuitive approaches to make the decision simpler, and in the process, important information can be ignored. In this context, when considering multiple criteria, simultaneously, in addition to the uncertainties associated with each choice with management of discordance between decision makers, the process becomes more transparent and robust. The Multiple Criteria Decision Analysis - MCDA is a set of methods, in this perspective, the choice of the highest value anticoagulant in the decision makers' preference was discussed. This study aimed to develop a conceptual framework with the MACBETH method in a hospital context of prevention of deep vein thrombosis in the postoperative period of knee and hip arthroplasty. The criteria and alternatives were selected in an interview with stakeholders. Performance was estimated by rapid literature review and meta-analysis of clinical trials. The model, including the weights, was elaborated in a decision conference, where the qualitative judgment of the preferences occurred in a consensual way. Sensitivity and robustness analysis was performed after the conference. Rivaroxaban was the most valuable anticoagulant for the prophylaxis scenario of DVT, and the most important criteria in the decision makers' opinion were: "Death from any cause", "Clinically important bleeding" and "Prevention of proximal deep vein thrombosis." The total cost of treatment did not interfere with the results of the model. The successful use of the MACBETH method, with a conference of decision-makers in a tertiary hospital, validates its use as a tool to support management by helping to make transparent, robust and defensible decisions in the face of the most complex scenario facing hospitals.
Total knee replacement and total hip replacement are large orthopedic surgeries that present a risk of surgical and clinical complications, of which the most prevalent is deep vein thrombosis. Without prophylaxis, the incidence of deep venous thrombosis varies between 40 and 60%. The use of anticoagulants is recommended by international guidelines to avoid this complication. There are several oral and injectable anticoagulants on the market, in practice the use may vary between institutions and according to the preference of the physician. Enoxaparin is the most commonly used anticoagulant in the National Institute of Traumatology and Orthopedics. Compared with it, oral anticoagulants can offer greater comfort, with similar or superior efficacy, but with a higher risk of bleeding, characterizing a scenario that involves uncertainties and risks, implying the need to make choices in situations where multiple groups can suffer the impacts long-term decision. Decision makers, when arriving at a rational resolution without support, tend to use heuristic or intuitive approaches to make the decision simpler, and in the process, important information can be ignored. In this context, when considering multiple criteria, simultaneously, in addition to the uncertainties associated with each choice with management of discordance between decision makers, the process becomes more transparent and robust. The Multiple Criteria Decision Analysis - MCDA is a set of methods, in this perspective, the choice of the highest value anticoagulant in the decision makers' preference was discussed. This study aimed to develop a conceptual framework with the MACBETH method in a hospital context of prevention of deep vein thrombosis in the postoperative period of knee and hip arthroplasty. The criteria and alternatives were selected in an interview with stakeholders. Performance was estimated by rapid literature review and meta-analysis of clinical trials. The model, including the weights, was elaborated in a decision conference, where the qualitative judgment of the preferences occurred in a consensual way. Sensitivity and robustness analysis was performed after the conference. Rivaroxaban was the most valuable anticoagulant for the prophylaxis scenario of DVT, and the most important criteria in the decision makers' opinion were: "Death from any cause", "Clinically important bleeding" and "Prevention of proximal deep vein thrombosis." The total cost of treatment did not interfere with the results of the model. The successful use of the MACBETH method, with a conference of decision-makers in a tertiary hospital, validates its use as a tool to support management by helping to make transparent, robust and defensible decisions in the face of the most complex scenario facing hospitals.
Description
Palavras-chave
Multicriteria decision analysis, Health technology assessment, Decision support techniques, MACBETH, Total knee arthroplasty, Total hip arthroplasty, ADMC, Artroplastia total de quadril, Artroplastia total de joelho, MACBETH, Técnicas de apoio à decisão, Avaliação de tecnologias em saúde, Análise de decisão multicritérios, MCDA
Citação
Morais QCD. Análise de decisão multicritério - MCDA - em hospital terciário: prevenção de trombose venosa profunda em cirurgias ortopédicas de grande porte. Rio de Janeiro. Dissertação [Mestrado Profissional em Ciências Cardiovasculares] - Instituto Nacional de Cardiologia; 2017.