The AMPDECIDE Patient Decision Aids: Empowering Veteran Participation in Personalized Amputation Level Decision-making

Va Puget Sound Healthcare System, Seattle WA

Investigators

Abstract

The choice of amputation level among Veterans facing amputation secondary to diabetes and/or peripheral artery disease can have profound effects on many functional outcomes. Informing patients of their likely key functional outcomes (i.e., mortality, reamputation, restoration of mobility) at each amputation level, enables them to pursue outcomes consistent with their values and priorities and provides an opportunity to spend the remaining functional life years maximizing quality of life. Patient decision aids (PtDAs) have been identified as important tools to enhance this process by serving as catalysts to engage patients in shared decision-making (SDM) processes; however, with respect to amputation level, patients have historically not participated in the decision- making process. The fundamental goal of the proposed research is to enable Veterans facing a dysvascular lower extremity amputation to participate in amputation level decision making, by informing them of their personalized outcome risks at each amputation level, and by assisting them in determining their outcome priorities and preferences. Since each amputation level is associated with different functional outcomes and competing healing risks, PtDAs that offer patients their unique, personalized outcomes will help ensure that the chosen level aligns with a patient’s unique priorities and preferences, thereby contributing to optimal function, quality of life (QoL), and participation in community activities that are important to them. Our research team has developed a physician-facing AMPREDICT Decision Support Tool (DST) that predicts the individual patient specific risk of 12-month mortality, reamputation, and independent mobility at each major lower extremity amputation level (transmetatarsal (TM), transtibial (TT) and transfemoral (TF)), which has now been successfully integrated into the VHA electronic health record (EHR). We have also developed patient-facing non-personalized AMPDECIDE TM/TT and TT/TF PtDAs that present population average risks, rather than personalized risks; these are currently housed in the AMPDECIDE web portal which is external to the EHR. Pilot results evaluating usability and feasibility of the PtDAs indicate that 54% of patients would have preferred to make the final amputation level decision and 27% indicated they would have preferred to share in the decision with their provider, leaving a very small proportion who would not want to participate in amputation level shared decision making. Further, nearly all patients expressed interest in learning about their personalized outcomes. To achieve the known benefits of SDM engagement, an emerging opportunity is to incorporate decision making tools into the EHR; PtDAs integrated into the EHR demonstrate high and sustained adoption rates. This study involves the development and validation of the technology to create personalized PtDAs available within the EHR by integrating them with the personalized risks generated from the AMPREDICT DST, allowing Veteran patients facing amputation to view the personalized aids within a clinical encounter, presenting a tremendous opportunity to engage in the amputation level decision, which will lead to functional, QoL, and participation outcomes that align with patients’ priorities and preferences for their remaining life years. More specifically, the goals of this grant are threefold. First, we will develop and validate the technology to create personalized AMPDECIDE patient decision aids that provide individual patient specific risks of key functional outcomes at each major lower extremity amputation level. Access to the decision aids through the EHR will facilitate point of care access. Second, we will evaluate the efficacy of the personalized AMPDECIDE PtDAs, compared to standard of care, in improving patient knowledge and reducing decisional conflict (primary efficacy measures), regarding their personal trade-offs of each amputation level. Secondary efficacy measures will include improvement in shared decision making, decisional satisfaction and impact on QoL. Finally, we will identify barriers and facilitators to implementation of the personalized AMPDECIDE PtDAs through a formative evaluation with provider participants and key stakeholders, which will guide implementation of the AMPDECIDE tools VA-wide.