| Research evidence |
We would pool across different types of general surgeries and we would try to use that evidence or compare whether or not that evidence that is pooled, and that is somewhat indirect for this specific population, [but] is better than the evidence that we have here which is mainly plagued by imprecision. The concern is that you might just be pooling bad data, throwing bad data together, and you may have some good data in there that you throw together with bad data…so anyway. But the concept for now is we didn’t specifically review this evidence, we didn’t do the search, we didn’t do the deconstruction; we used what the treatment for today and tomorrow the treatment panel gave us. |
| Resource use and costs |
So cost-effectiveness, meaning these assumptions about the events, does that then lead to spending the resources? Does that provide important benefit as opposed to just the cost. We can make recommendations or suggestions that assume a resource like an SRA is available and then also recommend that if that resource is not available. |
| Balance of benefits and harms |
Inconsistencies, so do some of the study show benefit and some of the study show harm and there’s differences in effect across the studies? In other words if you believe that the benefits don’t clearly outweigh the risk or the risk don’t clearly outweigh the benefits, or you think they are not relevant, that shifts our confidence levels for some of these outcomes. And…my physician made a decision [that] it was worth the risk when, you know the risk of bleeding if it’s monitored correctly and you know what to look for, at least in my case, was worth it; was worth more than the harm of possibly thrombosis. |
| Feasibility and acceptability |
Feasibility, acceptability and accessibility is okay; it may be similar in my country but when you go to other third world where it is been completely different. And acceptability, of course you may find something that is evidence-based, cost acceptable, feasible, and then no one wants to do it. Only consider an MRV [magnetic resonance venography] depending on availability because you can’t say to people that you have to do and MRV when 50% of the countries can’t get access. |
| Patient values and preferences |
I personally would say strong here just because of the level, the moderate evidence and the benefits in terms of acceptability from patient preferences standpoint. A personally I would say is almost a tie, so it can’t be strongly supported but it can be left to patient values and preferences. I don’t know. Could we say or would people feel comfortable, if we said we suggest against routine platelet count monitoring in medical patients receiving unfractionated heparin and then the values and preferences thing or do you feel like that is already too strong? |
| Health equity |
And these concepts are obviously closely tied to issues around feasibility, acceptability and equity. Health-equity though, in this case I think it holds because it means better compliance amongst patients with lower health literacy. The US healthcare system, if going to get into that say your treatment is going to be improved by testing and accost you 2,000 bucks and you don’t have coverage for, that’s going to increase health inequity. |
| Clinical experience |
I have the gestalt this [situation] is not good then I am asking my best ultrasound clinician to go up really high. If the suspicion remains then sure, but so I instruct my patients that I think follow up point. So we can’t pin down those risk factors and we are instead relying on gestalt of this surgeon. Probably we shouldn’t be too prescriptive about it and have two specific recommendations. So generally we can either use what we have called in our discussions is the ‘gestalt’, where you would just say based on what I think clinically I think that this person is at risk of having HIT? |
| Political environment |
And it might come at a cost but those costs are, those costs are of course caused by external people and if within this guideline you get an argument that we’re recommending low molecular weight over unfractionated and that will help drive your political efforts to try and get the funding costs down because they’ll say ‘look at [what] ASH said, we should be using this’.
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| Legal context |
These guidelines will have quite some medical legal implications and therefore I, we should clearly state that if the 4T score is properly performed and below four then maintaining, there is no, no reason to really change management.
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| Language in guideline |
I think we all want to be as transparent as we can. I think the bottom line is a long as we are explicit and sort of just say this is the rationale where we put it is a bit semantic. But you are absolutely right; it needs to be transparently laid out that there are assumptions going into this. |
