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Medical Decision Making
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Markov Models in Medical Decision Making

A Practical Guide

Frank A. Sonnenberg, MD

J. Robert Beck, MD

Markov models are useful when a decision problem involves risk that is continuous over time, when the timing of events is important, and when important events may happen more than once. Representing such clinical settings with conventional decision trees is difficult and may require unrealistic simplifying assumptions. Markov models assume that a patient is always in one of a finite number of discrete health states, called Markov states. All events are represented as transitions from one state to another. A Markov model may be evaluated by matrix algebra, as a cohort simulation, or as a Monte Carlo simulation. A newer repre sentation of Markov models, the Markov-cycle tree, uses a tree representation of clinical events and may be evaluated either as a cohort simulation or as a Monte Carlo simulation. The ability of the Markov model to represent repetitive events and the time dependence of both probabilities and utilities allows for more accurate representation of clinical settings that involve these issues. Key words: Markov models; Markov-cycle decision tree; decision mak ing. (Med Decis Making 1993;13:322-338)

Medical Decision Making, Vol. 13, No. 4, 322-338 (1993)
DOI: 10.1177/0272989X9301300409
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 Diabetes CareHome page
N. Aoki, K. Dunn, T. Fukui, J. R. Beck, W. J. Schull, and H. K. Li
Cost-Effectiveness Analysis of Telemedicine to Evaluate Diabetic Retinopathy in a Prison Population
Diabetes Care, May 1, 2004; 27(5): 1095 - 1101.
[Abstract] [Full Text] [PDF]

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 StrokeHome page
S. Kwon, A. G. Hartzema, P. W. Duncan, and S. Min-Lai
Disability Measures in Stroke: Relationship Among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale
Stroke, April 1, 2004; 35(4): 918 - 923.
[Abstract] [Full Text] [PDF]

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 StrokeHome page
R. Launois, M. Giroud, A.C. Megnigbeto, K. Le Lay, G. Presente, M.H. Mahagne, I. Durand, and A.F. Gaudin
Estimating the Cost-Effectiveness of Stroke Units in France Compared With Conventional Care
Stroke, March 1, 2004; 35(3): 770 - 775.
[Abstract] [Full Text] [PDF]

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 JNCI J Natl Cancer InstHome page
C. Hur, N. S. Nishioka, and G. S. Gazelle
Cost-Effectiveness of Aspirin Chemoprevention for Barrett's Esophagus
J Natl Cancer Inst, February 18, 2004; 96(4): 316 - 325.
[Abstract] [Full Text] [PDF]

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 JNCI J Natl Cancer InstHome page
J. J. Telford, J. R. Saltzman, K. M. Kuntz, and S. Syngal
Impact of Preoperative Staging and Chemoradiation Versus Postoperative Chemoradiation on Outcome in Patients With Rectal Cancer: A Decision Analysis
J Natl Cancer Inst, February 4, 2004; 96(3): 191 - 201.
[Abstract] [Full Text] [PDF]

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 HypertensionHome page
H. D. Sesso, R. S. Chen, G. J. L'Italien, P. Lapuerta, W. C. Lee, and R. J. Glynn
Blood Pressure Lowering and Life Expectancy Based on a Markov Model of Cardiovascular Events
Hypertension, November 1, 2003; 42(5): 885 - 890.
[Abstract] [Full Text] [PDF]

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 Med Decis MakingHome page
A. H. Briggs, A. E. Ades, and M. J. Price
Probabilistic Sensitivity Analysis for Decision Trees with Multiple Branches: Use of the Dirichlet Distribution in a Bayesian Framework
Med Decis Making, July 1, 2003; 23(4): 341 - 350.
[Abstract] [PDF]

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 Ann OncolHome page
V. Cocquyt, K. Moeremans, L. Annemans, P. Clarys, and S. Van Belle
Long-term medical costs of postmenopausal breast cancer therapy
Ann. Onc., July 1, 2003; 14(7): 1057 - 1063.
[Abstract] [Full Text] [PDF]

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 JCOHome page
R. S. Punglia, K. M. Kuntz, J. H. Lee, and A. Recht
Radiation Therapy Plus Tamoxifen Versus Tamoxifen Alone After Breast-Conserving Surgery in Postmenopausal Women With Stage I Breast Cancer: A Decision Analysis
J. Clin. Oncol., June 15, 2003; 21(12): 2260 - 2267.
[Abstract] [Full Text] [PDF]

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 Med Decis MakingHome page
S. J. Goldie and K. M. Kuntz
A Potential Error in Evaluating Cancer Screening: A Comparison of 2 Approaches for Modeling Underlying Disease Progression
Med Decis Making, May 1, 2003; 23(3): 232 - 241.
[Abstract] [PDF]

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 ANN INTERN MEDHome page
J. M. Inadomi, R. Sampliner, J. Lagergren, D. Lieberman, A M. Fendrick, and N. Vakil
Screening and Surveillance for Barrett Esophagus in High-Risk Groups: A Cost-Utility Analysis
Ann Intern Med, February 4, 2003; 138(3): 176 - 186.
[Abstract] [Full Text] [PDF]

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 Rheumatology (Oxford)Home page
G. Kobelt, L. Jonsson, A. Young, and K. Eberhardt
The cost-effectiveness of infliximab (Remicade(R)) in the treatment of rheumatoid arthritis in Sweden and the United Kingdom based on the ATTRACT study
Rheumatology, February 1, 2003; 42(2): 326 - 335.
[Abstract] [Full Text] [PDF]

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 Med Decis MakingHome page
M. Brisson and W. J. Edmunds
Economic Evaluation of Vaccination Programs: The Impact of Herd-Immunity
Med Decis Making, January 1, 2003; 23(1): 76 - 82.
[Abstract] [PDF]

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 J. Am. Soc. Nephrol.Home page
S. V. Jassal, M. D. Krahn, G. Naglie, J. S. Zaltzman, J. M. Roscoe, E. H. Cole, and D. A. Redelmeier
Kidney Transplantation in the Elderly: A Decision Analysis
J. Am. Soc. Nephrol., January 1, 2003; 14(1): 187 - 196.
[Abstract] [Full Text] [PDF]

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 Stat Methods Med ResHome page
N J Cooper, A J Sutton, and K R Abrams
Decision analytical economic modelling within a Bayesian framework: application to prophylactic antibiotics use for caesarean section
Statistical Methods in Medical Research, December 1, 2002; 11(6): 491 - 512.
[Abstract] [PDF]

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 Med Decis MakingHome page
D. K. Owens
Analytic Tools for Public Health Decision Making
Med Decis Making, October 1, 2002; 22(5_suppl): S3 - S10.
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 Med Decis MakingHome page
P. V. Pepper and D. K. Owens
Cost-Effectiveness of the Pneumococcal Vaccine in Healthy Younger Adults
Med Decis Making, October 1, 2002; 22(5_suppl): S45 - S57.
[Abstract] [PDF]

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 J Am Coll CardiolHome page
G. J. Blake, P. M. Ridker, and K. M. Kuntz
Projected life-expectancy gains with statin therapy for individuals with elevated c-reactive protein levels
J. Am. Coll. Cardiol., July 3, 2002; 40(1): 49 - 55.
[Abstract] [Full Text] [PDF]

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 Med Decis MakingHome page
K. M. Kuntz and S. J. Goldie
Assessing the Sensitivity of Decision-Analytic Results to Unobserved Markers of Risk: Defining the Effects of Heterogeneity Bias
Med Decis Making, June 1, 2002; 22(3): 218 - 227.
[Abstract] [PDF]

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 JCOHome page
J. H. Lee, H. A. Glick, J. A. Hayman, and L. J. Solin
Decision-Analytic Model and Cost-Effectiveness Evaluation of Postmastectomy Radiation Therapy in High-Risk Premenopausal Breast Cancer Patients
J. Clin. Oncol., June 1, 2002; 20(11): 2713 - 2725.
[Abstract] [Full Text] [PDF]

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 ANN INTERN MEDHome page
G. D. Sanders, M. A. Hlatky, N. R. Every, K. M. McDonald, P. A. Heidenreich, L. S. Parsons, and D. K. Owens
Potential Cost-Effectiveness of Prophylactic Use of the Implantable Cardioverter Defibrillator or Amiodarone after Myocardial Infarction
Ann Intern Med, November 20, 2001; 135(10): 870 - 883.
[Abstract] [Full Text] [PDF]

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 Eval RevHome page
A. P. Johnson-Masotti, P. W. Laud, R. G. Hoffmann, M. J. Hayat, and S. D. Pinkerton
Probabilistic Cost-Effectiveness Analysis of HIV Prevention: Comparing a Bayesian Approach With Traditional Deterministic Sensitivity Analysis
Eval Rev, August 1, 2001; 25(4): 474 - 502.
[Abstract] [PDF]

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 ANN INTERN MEDHome page
M. C. Weinstein, S. J. Goldie, E. Losina, C. J. Cohen, J. D. Baxter, H. Zhang, A. D. Kimmel, and K. A. Freedberg
Use of Genotypic Resistance Testing To Guide HIV Therapy: Clinical Impact and Cost-Effectiveness
Ann Intern Med, March 20, 2001; 134(6): 440 - 450.
[Abstract] [Full Text] [PDF]

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 Tobacco ControlHome page
M. E Orme, S. L Hogue, L. M Kennedy, A. C Paine, and C. Godfrey
Development of the health and economic consequences of smoking interactive model
Tob. Control, March 1, 2001; 10(1): 55 - 61.
[Abstract] [Full Text]

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 ANN INTERN MEDHome page
C. H.F. Cheng, G. D. Sanders, M. A. Hlatky, P. Heidenreich, K. M. McDonald, B. K. Lee, M. S. Larson, and D. K. Owens
Cost-Effectiveness of Radiofrequency Ablation for Supraventricular Tachycardia
Ann Intern Med, December 5, 2000; 133(11): 864 - 876.
[Abstract] [Full Text] [PDF]

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 ANN INTERN MEDHome page
A. Sonnenberg, F. Delco, and J. M. Inadomi
Cost-Effectiveness of Colonoscopy in Screening for Colorectal Cancer
Ann Intern Med, October 17, 2000; 133(8): 573 - 584.
[Abstract] [Full Text] [PDF]