使用多准则决策分析比较截肢水平结局的患者和提供者的优先事项。
Comparing Patient and Provider Priorities Around Amputation Level Outcomes Using Multiple Criteria Decision Analysis.
机构信息
Advanced Methods Development, RTI International, Research Triangle Park, NC; Department of Health Services, University of Washington, Seattle, WA.
Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
出版信息
Ann Vasc Surg. 2023 Sep;95:169-177. doi: 10.1016/j.avsg.2023.05.026. Epub 2023 May 30.
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.
背景
患有慢性肢体威胁性缺血的患者可能需要进行经跖骨截肢术（TMA）或经胫骨截肢术。在做出截肢水平的决策时，这些患者面临着权衡取舍 - TMA 保留了更多的肢体，可能提供更好的活动能力，但原发伤口愈合的可能性较低，因此可能导致更多相同或更高水平的截肢手术，从而对功能产生负面影响。了解患者和提供者在权衡这些取舍和其他结果方面的差异可能会增强共同决策。
目的
使用多准则决策分析（MCDA）比较患者的优先事项与提供者对患者优先事项的看法。
方法
由于认知负担低且易于实施，因此选择了 MCDA 层次分析法。我们纳入了 5 个标准（结果）：行走能力，截肢手术后的愈合，康复计划强度，肢体长度和假肢/矫形器的易用性。从退伍军人健康管理局招募了全国范围内的血管功能障碍下肢截肢患者和提供者，通过在线向提供者和电话向患者提供 MCDA。
结果
有 26 名血管功能障碍的截肢患者和 38 名提供者参加了研究。有 50％的患者接受了 TMA；50％的患者接受了经胫骨截肢术。与提供者相比，患者更看重 TMA（72％对 63％）。患者与提供者的优先级是行走能力（47％对 42％），愈合（18％对 28％），假体使用的便利性（17％对 13％），肢体长度（11％对 13％），然后是康复强度（7％对 6％）。
局限性
我们的样本可能不适用于其他人群。
结论
提供者的看法与患者在截肢水平上的价值观相符，但在每个结果的重要性上存在差异。
含义
这些发现阐明了患者价值观与提供者对患者价值观的看法之间的一些差异，表明共同决策的作用。将这个 MCDA 框架嵌入到未来的决策辅助工具中可能会促进这些讨论。
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