Is There a Role for Surgery in the Acute Management of Infectiue Endocarditis?

In the absence of good clinical evidence from a randomized trial, the authors performed a decision analysis to determine the potential value of early elective surgery (OPNOW) for patients with left-sided Staphylococcus aureus infective endocarditis. Initial impressions (before per formance of decision analysis) and initial runs at the formal models using probability estimates derived from clinicians suggested that OPNOW (i.e., within a few days of starting antibiotics) offered no advantage over attempted medical cure (WAIT) (life expectancy: WAIT = 325 weeks; OPNOW = 255 weeks). Extensive sensitivity analyses identified critical variables that needed further empirical estimation. The Manitoba Health Services Commission database identified 127 incident cases of endocarditis between April 1, 1979, and March 31, 1985, enabling estimation of values for these critical variables. With these estimates, the early surgery strategy appeared much better than the previous analyses had suggested (life expectancy: WAIT = 208 weeks, OPNOW = 256 weeks). The authors believe that this approach of com bining decision analysis with medical claims databases is useful as an alternative or precursor to randomized trials, especially where the resource requirements and logistic difficulties of performing randomized trials are great. Key words: infective endocarditis; valve replacement; therapy; databases. (Med Decis Making 8:165-174, 1988)