Comparing Patient and Provider Priorities Around Amputation Level Outcomes Using Multiple Criteria Decision Analysis

Abstract

Background: Patients with chronic limb threatening ischemia may require a transmetatarsal amputation (TMA) or a transtibial amputation. When making an amputation-level decision, these patients face a tradeoff-a TMA preserves more limb and may provide better mobility but has a lower probability of primary wound healing and may therefore result in additional same or higher level amputation surgeries with an associated negative impact on function. Understanding differences in how patients and providers prioritize these tradeoffs and other outcomes may enhance shared decision-making.

Objectives: Compare patient priorities with provider perceptions of patient priorities using Multiple Criteria Decision Analysis (MCDA).

Methods: The MCDA Analytic Hierarchy Process was chosen due to its low cognitive burden and ease of implementation. We included 5 criteria (outcomes): ability to walk, healing after amputation surgery, rehabilitation program intensity, limb length, and ease of use of prosthetic/orthotic device. A national sample of dysvascular lower-limb amputees and providers were recruited from the Veterans Health Administration with the MCDA administered online to providers and telephonically to patients.

Results: Twenty-six dysvascular amputees and 38 providers participated. Fifty percent of patients had undergone a TMA; 50%, a transtibial amputation. When compared to providers, patients placed higher value on TMA (72% vs. 63%). Patient versus provider priorities were ability to walk (47% vs. 42%), healing (18% vs. 28%), ease of prosthesis use (17% vs. 13%), limb length (11% vs. 13%), and then rehabilitation intensity (7% vs. 6%).

Limitations: Our sample may not generalize to other populations.

Conclusions: Provider perceptions aligned with patient values on amputation level but varied around the importance of each outcome.

Implications: These findings illuminate some differences between patients' values and provider perceptions of patient values, suggesting a role for shared decision-making. Embedding this MCDA framework into a future decision aid may facilitate these discussions.

Fig. 1.

Criteria specific valuation between provider beliefs and patient values.

Fig. 2.

Comparison of provider beliefs around criteria by provider specialty.

Fig. 3.

Comparison of provider beliefs around amputation by provider specialty.