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Decision Tree — Knee Replacement Now or Conservative Care (QALYs)

Severe knee osteoarthritis with a downstream decision: replacing the knee now rolls back to 6.64 QALY over ten years against 5.84 QALY for conservative care, which itself carries a year-3 choice where delayed replacement beats staying conservative after progression. Illustrative values for teaching, not clinical guidance.

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Severe knee osteoarthritis — replace now or manage conservatively?Severe knee osteoarthritis — replace now or manage conservatively?Quality-adjusted life years over 10 years for a 68-year-old, discounted2 decisions · 3 chance nodes · 11 outcomes · maximise expected valueOPTIMAL STRATEGYTotal knee replacement·EV 6.64 QALYConservative careStable45%Progression55%Delayed knee replacementStay on conservative careGood function81.4%Persistent pain17%Periprosthetic joint infection1.2%Death within 90 days0.4%Symptoms over three yearsEV 5.84 QALY5.9 QALYRevisit at year 3EV 5.79 QALYOutcome after delayedsurgeryEV 5.79 QALY6.0 QALY5.0 QALY4.3 QALY0 QALY4.6 QALYTotal knee replacementGood function78.7%Persistent pain15%Revision within 10 years5%Periprosthetic joint infection1%Death within 90 days0.3%Treatment nowEV 6.64 QALYOutcome at one yearEV 6.64 QALY6.9 QALYP 78.7%5.8 QALYP 15%5.9 QALYP 5%4.9 QALYP 1%0 QALYP 0.3%DecisionChanceOutcomeOptimal strategyRejected alternativeWhat the rollback showsBest first choice: “Total knee replacement”, EV 6.64 QALY — 0.81 QALY ahead of the next best, “Conservative care” (5.84 QALY).Following it, the outcome ranges from 0 QALY to 6.9 QALY across 5 possible results, standard deviation 0.59 QALY.Note: Outcome rates are of the order reported in arthroplasty registries; utilities are illustrative.Note: Illustrative values for teaching — not clinical guidance.

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title "Severe knee osteoarthritis — replace now or manage conservatively?"
subtitle "Quality-adjusted life years over 10 years for a 68-year-old, discounted"
unit QALY
probabilities percent
note "Outcome rates are of the order reported in arthroplasty registries; utilities are illustrative."
note "Illustrative values for teaching — not clinical guidance."

decision "Treatment now"
  "Total knee replacement" -> chance "Outcome at one year"
    "Good function" p rest -> 6.9
    "Persistent pain" p 15% -> 5.8
    "Revision within 10 years" p 5% -> 5.9
    "Periprosthetic joint infection" p 1% -> 4.9
    "Death within 90 days" p 0.3% -> 0
  "Conservative care" -> chance "Symptoms over three years"
    "Stable" p 45% -> 5.9
    "Progression" p rest
      decision "Revisit at year 3"
        "Delayed knee replacement" -> chance "Outcome after delayed surgery"
          "Good function" p rest -> 6.0
          "Persistent pain" p 17% -> 5.0
          "Periprosthetic joint infection" p 1.2% -> 4.3
          "Death within 90 days" p 0.4% -> 0
        "Stay on conservative care" -> 4.6