Prospective decision analysis modeling indicates that clinical decisions in vascular surgery often fail to maximize patient expected utility

Cox, Monty H.; Robison, Jacob G.; Elliott, Bruce M.; Nietert, Paul J.

doi:10.1016/j.jss.2004.01.004

Cited by 26 publications

(35 citation statements)

References 31 publications

(23 reference statements)

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“…Bearing in mind that clinicians are not accurate in judging patient values for the outcome of care (Cotler et al, 2001;Montgomery and Fahey, 2001;Brothers et al, 2004;Stalmeier et al, 2007), it seems in these cases critical to ascertain that the patient persists in preferring non-involvement.…”

Section: Discussionmentioning

confidence: 99%

“…Involving patients in treatment-related decision making is in line with the increasingly acknowledged patients' right to autonomy and self-determination. The need to involve patients is supported by evidence that physicians do not have the ability to adequately judge patients' values for outcomes of care (Cotler et al, 2001;Montgomery and Fahey, 2001;Brothers et al, 2004;Stalmeier et al, 2007).…”

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confidence: 99%

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Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration

et al. 2008

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Patient participation in treatment decision-making is being increasingly advocated, although cancer treatments are often guidelinedriven. Trade-offs between benefits and side effects underlying guidelines are made by clinicians. Evidence suggests that clinicians are inaccurate at predicting patient values. The aim was to assess what role oncologists and cancer patients prefer in deciding about treatment, and how they view patient participation in treatment decision-making. Seventy disease-free cancer patients and 60 oncologists (surgical, radiation, and medical) were interviewed about their role preferences using the Control Preferences Scale (CPS) and about their views on patient participation using closed-and open-ended questions. Almost all participants preferred treatment decisions to be the outcome of a shared process. Clinicians viewed participation more often as reaching an agreement, whereas 23% of patients defined participation exclusively as being informed. Of the participants, X81% thought not all patients are able to participate and X74% thought clinicians are not always able to weigh the pros and cons of treatment for patients, especially not quality as compared with length of life. Clinicians seemed reluctant to share probability information on the likely impact of adjuvant treatment. Clinicians should acknowledge the legitimacy of patients' values in treatment decisions. Guidelines should recommend elicitation of patient values at specific decision points.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration

et al. 2008

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“…To reflect catheterassociated morbidity during access maturation, the utility for catheter was applied to maturing access states. Disutilities of Ϫ0.08 and Ϫ0.1 were applied to reflect morbidity associated with percutaneous (i.e., arteriogram, declot, catheter placement) and surgical procedures, respectively, when patients were probabilistically determined to require these (16). The monthly probability of blood stream infection related to each access state was identified from published data (17), and state rewards were reduced by the product of this probability times a disutility of Ϫ0.6 for sepsis (18).…”

Section: Transition Probabilities Utilities and Costsmentioning

confidence: 99%

Choice of Vascular Access among Incident Hemodialysis Patients

Hou¹,

Lacson²,

Wang³

et al. 2010

Clinical Journal of the American Society of Nephrology

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Background and objectives: Arteriovenous fistulas (AVFs) are widely accepted as the preferred hemodialysis vascular access type. However, supporting data have failed to consider morbidity and mortality incurred during failed creation attempts and may therefore overstate potential advantages. This study compares survival, quality-adjusted survival, and costs among incident hemodialysis patients after attempted placement of AVFs or arteiovenous grafts (AVGs).Design, setting, participants, & measurements: Analogous Markov models were created, one each for AVF and AVG. Patients entered consideration at the time of first access creation, contemporaneous with dialysis initiation. Subsequent outcomes were determined probabilistically; transition probabilities, utilities, and costs were gathered from published sources. To ensure comparability between AVFs and AVGs, the timing and likelihood of access maturation were measured in a contemporary cohort of incident hemodialysis patients.Results: Mean (SD) overall survival was 39.2 (0.8) and 36.7 (1.0) months for AVFs and AVGs, respectively: difference (95% confidence interval [CI]) 2.6 (1.8, 3.3) months. Quality-adjusted survival was 36.1 (0.8) and 32.5 (0.9) quality-adjusted life months (QALMs) for AVFs and AVGs, respectively: difference (95% CI) 3.6 (2.8, 4.3) QALMs. The incremental costeffectiveness ratio (95% CI) for AVFs relative to AVGs was $446 (؊6023, 6994) per quality-adjusted life year saved.Conclusions: AVFs are associated with greater overall and quality-adjusted survival than AVGs. Observed differences were much less pronounced than might be expected from existing literature, suggesting that prospective identification of patients at high risk for AVF maturational failure might enable improvements in health outcomes via individualization of access planning.

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“…6 The DA model was subsequently expanded to include a broader spectrum of severity of PAD as well as adding the option of endovascular revascularization. 7,8 An alternative route to decision making, the Lower Extremity Grading System (LEGS) score, derived by consensus from a panel of vascular specialists and validated on subsequent patients has also been reported to improve planning of therapy. 9,10 The LEGS score appears to be less cumbersome than the Markov model, although it does not address primary medical therapy alone as an option.…”

Section: Introductionmentioning

confidence: 99%

Failure of Patients with Peripheral Arterial Disease to Accept the Recommended Treatment Results in Worse Outcomes

Brothers

2015

Annals of Vascular Surgery

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Mean cQOL improved most with direct revascularization, especially when the treatment received matched that predicted by the models or proposed by the surgeon. Type of treatment received was an independent predictor of agreement of treatment with recommendations. Patient refusal to follow the recommended treatment as well as the strategy not to revascularize claudicants who persist in smoking were associated with much less patient benefit from treatment.

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Prospective decision analysis modeling indicates that clinical decisions in vascular surgery often fail to maximize patient expected utility

Cited by 26 publications

References 31 publications

Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration

Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration

Choice of Vascular Access among Incident Hemodialysis Patients

Failure of Patients with Peripheral Arterial Disease to Accept the Recommended Treatment Results in Worse Outcomes

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