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A new methodology to compare clinical strategies with application in screening and diagnosis for cervical intraepithelial neoplasia (CIN).

6105 Background: Medical decision making seeks to help clinicians identify optimal clinical strategies. For example, one might want to identify conditions when "see and treat based on colposcopy" would be a better option than the current standard of care (SOC) for screening, diagnosing and detecting CIN. Comparing strategies requires quantifying the outcomes (expressed as losses) associated with different strategies. However, in many medical settings determining losses is difficult especially when considering both clinical and economic outcomes.


METHODS
We modeled the screening, diagnosis and detection of CIN as a Bayesian sequential decision problem. We compared the current SOC to several alternative clinical strategies involving the same sequence of tests (Papanicolaou smear, colposcopic exam, and biopsy).


RESULTS
We found that several alternative strategies for screening and diagnosis of CIN were always dominated. To consider our example, we used a dataset of 624 women to determine operating characteristics and found "see and treat based on colposcopy" is better than the SOC when the net loss for treating non-diseased individuals is less than 1.4 times the incremental loss associated with the biopsy (i.e. the loss associated with a colposcopically directed biopsy that is additional to the loss associated with colposcopy alone.) We also found that the strategy in which all patients receive a biopsy is better than the SOC whenever the loss associated with not treating diseased individuals is greater than 1.7 times the incremental cost of biopsy.


CONCLUSIONS
Our method provides an efficient means to compare clinical strategies based on both clinical and economic outcomes. No significant financial relationships to disclose.