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MEDINFO-406DL Summer 2011 Assignment 2 Due next week before class (July 6th by 6pm CST) The following questions present hypothetical clinical scenarios that can be modeled using a decision tree. Note: Include the tree and its analysis in your answers. Submit the final answers as a word document, not the images or TreeAge files. . 1. There is also a current TreeAge 2009 Manual that can be found on this page http://server.treeage.com/treeagepro/2005/install.asp#manuals. A substitute to above can be Chapter 2,3, 5 (Only RollBack Analysis Section) and 12. 2. There is also an animated demo and basic tutorial at http://server.treeage.com/treeagepro/support/demos/TreeAgeBasics.htm 3. Finally, there is a comprehensive Intro to TreeAge manual posted on blackboard with screenshots that is useful. Q1. You have a patient with gangrene in his foot, who has a choice between medicine or amputation. The clinical case outlined below uses life expectancy score on a scale of 01000 as a numerical indicator of relative desirability of different health states. Zero represents death and 1000 represents full health. If the patient chooses amputation of his foot, he has 99 percent chance of surviving (life expectancy score = 850). If the patient chooses medicine, he has a 5 percent chance of death, a 70 percent chance of full recovery (life expectancy score = 1000), and a 25 percent chance that his condition would worsen. In case of worsening of his condition, his leg maybe amputated or he will have to take more medicine. If his leg is amputated, his chances of survival will be 98 percent (life expectancy score = 700). If he chooses to take more medicine, he has a 60 percent chance of survival (life expectancy score = 995). Create a decision tree to calculate the expected value of each option in terms of life expectancy score. What would be the preferred option? Q2. Mr. Jones is a patient with a history of coronary artery disease (recovered uneventfully from a Myocardial Infarction 3 years ago). In preparation for an exercise regimen, investigations revealed 100% obstruction in right coronary artery. On admission, his tests revealed another issue- an encircling lesion of descending colon (Colon Cancer). The treatment is Colectomy (surgery). The key question is: Should a coronary artery bypass be performed to decrease the operative risk during Colectomy? Use the data given below for the following tasks: Page | 1

1. Perform a decision tree analysis to answer the key question stated above. 2. What is the gain in life expectancy (in years) that can be expected from the preferred approach? For each outcome below, consider life expectancy as the number of years adjusted for variations in the quality of life (Assume zero years for death). Mr. Jones has a choice to get coronary artery bypass first followed by Colectomy or an immediate Colectomy without coronary artery bypass. If he chooses coronary artery bypass, he has a 97 percent chance of surviving the bypass and going in for Colectomy. In case he survives and goes through Colectomy, he has 95 percent chance of surviving well (life expectancy = 4.25) and a 3 percent chance of surviving but with a perioperative M.I (life expectancy = 4.03). If he chooses immediate Colectomy, his chances of surviving well are 85% (life expectancy = 4.16) and surviving but with perioperative MI 10 percent (life expectancy = 3.95). Q3. You have an emphysema (lung disease) patient who has now developed crippling arthritis of both knees. His ability to survive the operation is in doubt (due his lung disease), and the surgery sometimes does not restore mobility to the degree required by the patient. His evaluation of various outcomes described below is measured in years of perfect mobility (called quality-adjusted life years or QALY*). If he chooses surgery, he has a 95 percent chance of surviving. If he survives, he has a 5 percent chance of contracting an infection. Once infected, he has a 95 percent chance of survival in which case he will be wheelchair bound (QALY = 3). If he survives surgery without an infection, there is a 60 percent chance of regaining full mobility (QALY = 10) and a 40 percent chance of poor mobility (QALY = 6). If he chooses not to go for surgery, he will live with poor mobility (QALY= 6). *Note: QALYs are commonly used as measures of utility (value) in medical decision analysis and in health policy analysis. In the above example, the patient decides that 10 years of poor mobility are equivalent to 6 years of normal mobility, whereas 10 years of wheelchair confinement are equivalent to only 3 years of full function. Answer the following questions: 1. Create a decision tree for this problem to calculate the excepted value of each option in terms of QALYs. What would be the preferred option? 2. Perform a sensitivity analysis of the effect of operative mortality on QALYs. What is the probability of operative death at which No surgery option becomes preferable? 3. Perform a second sensitivity analysis of the effect of a successful operative result on QALYs. What is the minimum probability of a successful result after which surgery becomes preferable?

Q4. A physician faces the decision to test an infant born to a mother who is infected with the human immunodeficiency virus (HIV) with the polymerase chain reaction (PCR), a gene-amplification technique that is useful for diagnosis of HIV infection in infants. The Page | 2

first decision is whether to perform PCR, and the second is whether to treat the infant. The outcome of interest is the quality-adjusted length of life (QALY). In case the physician orders PCR, the chance that PCR test shows HIV+ result is 9.68%. After getting this test result, the physician will decide to either treat or not treat the patient. Irrespective of whether he treats the patient or not, the chance that the patient is HIV+ is 80.99%. If PCR result shows HIV-, the physician again faces the decision of treating the patient or not. Irrespective of physicians decision, the chance of patient being HIV+ is 1.8%. Even if he does not obtain PCR, the physician still needs to decide if he will either treat the patient or not. Irrespective of his decision choice, the chance that the patient is HIV + is 8%. The value table associated with the various outcomes is given below. Value Table HIV+, Treated HIV+, Not treated HIV-, Treated HIV-, Not treated QALY 10.50 10.00 75.46 75.50

Answer the following questions: 1. Create a decision tree for the clinical case. What is the preferred course of action? 2. Extra credit: Draw a simple influence diagram for the problem above. (Note: you dont need to perform any numerical calculations in this regard. Only highlight the probabilistic relationships in an influence diagram).

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