[What to do in a 60-year-old HIV-positive woman with a cerebral arteriovenous malformation? Decision analysis].

OBJECTIVE

To illustrate how clinical decision analysis can contribute to modern medical practice.

DESIGN

Clinical decision analysis.

SETTING

Academic Hospital Rotterdam-Dijkzigt, Rotterdam, the Netherlands.

METHOD: Three treatment options (no treatment, neurosurgery and radiosurgery) for a 60-year-old HIV-positive woman with a once-ruptured cerebral arteriovenous malformation were compared using clinical decision analysis, with respect to the discounted quality adjusted life expectancy. Estimates of the risk of bleeding and its complications, of the efficacy and complications of treatment, and of the risk of developing AIDS and its consequences were based on the clinical literature.

RESULTS

Differences between no treatment and neurosurgery or radiosurgery amounted to 0.1 (plausible range: -0.27 to 0.84) and 0.2 (plausible range: -0.29 to 0.76) discounted quality adjusted life years, in favour of no treatment. The limited life expectancy of the patient, leading to a relatively low cumulative risk of haemorrhage, did not appear to justify the risks of treatment.

CONCLUSION

Clinical decision consultation may provide a rational, thorough and explicit decision procedure which takes into account the complexity of medical care.