Exploring Patient Preferences for Infrainguinal Bypass Operation

Prospective decision analysis for peripheral vascular disease predicts future quality of life

OBJECTIVE

Decision making for peripheral vascular disease can be quite complex as a result of pre-existing compromise of patient functional status, anatomic considerations, uncertainty of favorable outcome, medical comorbidities, and limitations in life expectancy. The ability of prospective decision-analysis models to predict individual quality of life in patients with lower extremity arterial occlusive disease was tested.

METHODS

This was a prospective cohort study. The settings were university and Veterans Administration vascular surgery practices. All 214 patients referred with symptomatic lower extremity arterial disease of any severity over a 2-year period were screened, and 206 were enrolled. A Markov model was compared with standard clinical decision-making. Utility assessment and generalized (Short Form-36; SF-36) and disease-specific (Walking Impairment Questionnaire; WIQ) quality of life were derived before treatment. Estimates of treatment outcome probabilities and intended and actual treatment plans were provided by attending vascular surgeons. The main outcome measures were generalized (SF-36) and disease-specific (WIQ) variables at study entry and at 4 and 12 months.

RESULTS

Primary intervention consisted of amputation for 9, bypass for 42, angioplasty for 8, and medical treatment for 147 patients. Considering all patients, no improvement in mean overall patient quality of life measured by the SF-36 Physical Component Score (27 +/- 8 vs 28 +/- 8; P = .87) or WIQ (39 +/- 22 vs 39 +/- 23; P = .13) was noted 12 months after counseling and treatment by the vascular surgeons. Individually considered SF-36 categories were improved only for Bodily Pain (40 +/- 23 vs 49 +/- 25; P = .03), with the most significant improvement observed among patients with the most severe pain (68 +/- 25 vs 37 +/- 23; P = .02) and among those undergoing bypass (60 +/- 29 vs 31 +/- 22; P = .02). It is noteworthy that when the treatment chosen was incongruent with the Markov model, patients were more likely to report a poorer quality of life at 1 year (Physical Component Score, 25 +/- 8 vs 29 +/- 8; P < .001). The quality of life predicted at baseline by the Markov model correlated positively with the Physical Component Score (r = 0.23), Bodily Pain (r = 0.33), and Fatigue (r = 0.44) and negatively with WIQ (r = -0.08) observed 1 year later.

CONCLUSIONS

Prospective application of an individualized decision Markov model in patients with vascular disease was predictive of patient quality of life at 1 year. The patient's outcome was worse when the treatment received did not follow the model's recommendation. This decision analysis model may be useful to identify patients at risk for poor outcomes with standard clinical decision making.

Brief report: do patients with poor outcomes regret having had infrainguinal bypass surgery?

BACKGROUND

Retrospection and hindsight bias may lead patients with bad outcomes to regret the choice of infrainguinal bypass surgery.

OBJECTIVE

To assess patients' retrospective evaluations of surgery stratified by common criteria to judge surgical success. SURVEY DESIGN: Cross-sectional phone surveys of 33 patients, an average of 162 d following infrainguinal bypass surgery.

RESULTS

Of the 33 patients evaluated, 26 (79%) experienced undesirable outcomes, including amputation (4, 12%), prolonged hospitalization (8, 24%), wound infection (8, 24%), readmission to the hospital (12, 36%), additional surgery (11, 33%), and other complications (16, 48%). Of the patients surveyed, nearly all (30, 91%) reported that they would still want to have had the surgery if they had a 5-y 50% mortality, and the same proportion reported they would recommend the surgery to someone else with similar medical problems (30, 91%).

CONCLUSIONS

If confirmed in larger populations, these findings suggest that when viewed retrospectively, results traditionally considered poor outcomes may not deter many patients' preferences for surgical management of their infrainguinal vascular disease.

A comparison of patient and physician beliefs about infrainguinal bypass operation: What role should surgical optimism play?

BACKGROUND

Risk and outcomes of infrainguinal bypass operation vary by identifiable patient characteristics. Previously, we found that although patients appear willing to undertake considerable risk, they may have unrealistic expectations for operative benefits. Little is known about whether patients and physicians have similar beliefs regarding the risks and benefits of the operation.

METHODS

Cross-sectional paired surveys of 6 surgeons and 45 of their patients undergoing infrainguinal bypass operation at a large university medical center.

RESULTS

Similar proportions of physicians and patients reported risks associated with the operation. There was moderate agreement within patient-surgeon pairs regarding specific risks such as the likely need for additional operations or for amputation despite the procedure (agreement ranging from 60% to 69% of patient-physician pairs). In nearly two thirds (62%) of cases surgeons provided more optimistic prognostic estimates of 5-year mortality than is suggested by prior research (McNemar test, P < .001). In turn, patients tended to be more optimistic regarding their estimated 5-year survival than their surgeons, with 56% of patients estimating a lesser 5-year mortality than that predicted by their surgeon (McNemar test, P < .01).

CONCLUSIONS

Although surgeons and patients generally agree regarding the risks of infrainguinal bypass operation, both groups appear more optimistic regarding likely 5-year survival than the outcomes suggested by prior research. This optimism may play an important role in the decision to proceed with infraninguinal bypass operation, as well as the preservation of hope regarding the potential long-term benefits of such intervention.