A qualitative study of factors influencing the decision to have an elective amputation

Development of a Patient Decision Aid for Distal Radius Fractures in Patients Aged ≥65 Years

PURPOSE

The ideal management of distal radius fractures (DRFs) in patients aged 65 years and older is debated. Acknowledging the evidence that both nonsurgical and surgical treatment yield similar outcomes one year after injury, a patient decision aid (PDA) could facilitate patient engagement in treatment decision-making. The purpose of this study was to develop a PDA to guide patients in the treatment of DRFs in patients ≥65 years of age.

METHODS

The DRF PDA was developed using an established decision sciences framework. The PDA included an overview of DRFs, treatment options (casting vs surgery), risk/benefits, and a values clarification section. During the development phase, hand surgeons and patients reviewed the PDA; then, semistructured interviews were performed with participants to elicit feedback.

RESULTS

Eleven patients and 11 hand surgeons participated in the study. All patients found the PDA useful and almost all stated it would make the treatment decision easier. Most patients believed that there was enough information in the PDA, but one desired more information about surgical risks. Almost all surgeons stated the PDA would be easy for patients to use and understand, and approximately half believed that it would help patients make a more informed decision. Most surgeons expressed that the PDA would complement their usual approach to counseling patients, but some noted it would involve changes to their workflow. Most participants believed the information presented was unbiased, but one patient thought it was biased toward surgery, whereas a few surgeons believed that it was biased toward nonsurgical treatment.

CONCLUSIONS

All patients expressed that the PDA was informative, comprehensive, and easy to understand and would be helpful if they were deciding about DRF treatment. Surgeons believed that patients would find the PDA easy to use and understand, but some had concerns about incorporating it into their clinic workflow.

CLINICAL RELEVANCE

A decision aid for the treatment of DRFs in patients aged ≥65 years can be used to engage patients in the shared decision-making process.

Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse

AIMS AND OBJECTIVES

To explore the notion of Being-with and authentic discourse for people making decisions about major amputation.

BACKGROUND

Chronic limb-threatening ischaemia is a devastating disease with a high burden of pain and complex wounds. Patients may deteriorate suddenly after multiple revascularisation procedures and, amputation is offered when further reperfusion is considered futile. Delayed decisions about amputation have negative consequences for patients, families and health systems, yet little attention is given to training clinicians for the sophisticated communication required. Clinicians need to engage in authentic discourse about amputation to create shared meaning and facilitate decision-making.

DESIGN

Qualitative study using hermeneutic Heideggerian phenomenology.

METHODS

Twelve patients offered major amputation, and 13 family participants from three vascular units in Australia engaged in 42 semi-structured interviews, representing 19 cases of chronic limb-threatening ischaemia. Hermeneutic phenomenology using the Heideggerian tenet of Being-with as an analytic framework, a philosophically based understanding of Being-with and Discourse related to treatment discussions and decisions was derived. The research was reported in accordance with the COREQ checklist.

FINDINGS

Effective discourse between the person and family was hampered by changed circumstances of Being-with, characterised by guilt, and a retreat from discourse through deficient discourse and filtering information. Clinician Being-with was hampered by discourse that was deficient, poorly delivered, discordant and disconnected through a lack of empathetic listening. There were also examples of enhanced clinician Being-with that made room for more constructive discourse and more timely decisions about amputation.

CONCLUSIONS

Heidegger's construct of Being-with provides a useful framework to reveal the role of authentic discourse in improving patient and family experience and decisions about treatment.

NO PATIENT OR PUBLIC CONTRIBUTION

This study did not engage consumers other than as patient and carer participants.

RELEVANCE TO CLINICAL PRACTICE

Decisions about amputation are often difficult for patients or family members who may be substitute decision-makers. A better understanding of the experience may assist clinicians in their interactions with patients and families.

Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery

PURPOSE

Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients' thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options.

METHODS

Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain's tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets.

RESULTS

Eight participants reported that patients have a general bias against being "knocked out," 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type.

CONCLUSIONS

Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery.

CLINICAL RELEVANCE

This study provides insights into patients' thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.

Why Rotationplasty? A Qualitative Study of Decision-Making by Families of Patients With Primary Bone Sarcoma

Rotationplasty is an established technique that is indicated as part of the surgical reconstruction for certain patients with primary bone tumors around the knee who undergo tumor resection. There is considerable variation in the application of rotationplasty by surgeons as well as acceptance of the procedure by patients who may be candidates for this procedure. We qualitatively studied the decision-making process of families of patients who had undergone rotationplasty by interviewing 4 patients and their families using semi-structured interviews. Thematic analysis identified the following themes that were important in the decision-making process: (1) the desire for good information sources, (2) finding value in meeting with other patients who had been faced with a similar decision, (3) prioritizing function over cosmesis, (4) a desire to limit the need for revision surgeries, and (5) accepting that a return to normalcy is not an option with a surgery. Physicians and patients faced with a similar decision can benefit from a better understanding of the process, and by the normalization of anxieties and concerns that they may experience.

Total joint replacement surgeon choice: A qualitative analysis in a medicare population

INTRODUCTION

Previous research has shown that patients from historically marginalized groups in the United States tend to have poorer outcomes after joint replacement surgery and that they are less likely to receive joint replacement surgery at high-volume hospitals. However, little is known regarding how this group of patients chooses their joint replacement surgeon. The purpose of this study was to understand the factors influencing the choice of joint replacement surgeon amongst a diverse group of patients.

METHODS

Semi-structured interviews were conducted with Medicare patients who underwent a hip or knee replacement within the last 24 months (N = 38) at an academic and community hospital. Interviews were audio recorded, transcribed and verified for accuracy. Transcripts were reviewed using iterative content analysis to extract key themes related to how respondents chose their joint replacement surgeon.

RESULTS AND DISCUSSION

MD referral/recommendation appears to be the strongest factor influencing joint replacement surgeon choice. Other key considerations are hospital reputation and surgeon attributes-including operative experience, communication skills, and participation in shared decision-making. Gender/ethnicity of a surgeon, industry payments to surgeons, number of publications and cost did not play a large role in surgeon choice.

CONCLUSION AND CLINICAL RELEVANCE

The process of choosing a joint replacement surgeon is a complex decision-making process with several factors at play. Despite growing availability of information regarding surgeons, patients largely relied on referrals for choosing their joint replacement surgeon regardless of ethnicity. Referring physicians need to ensure that patients are able to access hospital and surgeon outcomes, operative volume, and industry-payment information to learn more about their orthopedic surgeons in order to make an informed choice.

Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

BACKGROUND

The local treatment of extremity sarcomas usually is predicated on a decision between limb salvage and amputation. The manner in which surgical options are presented in the context of shared decision-making may influence this decision. In a population of "simulated" patients-survey respondents presented with a mock clinical vignette and then asked to choose between treatments-we assessed cognitive bias by deliberate alteration of the subjective presentation of the same objective information.

QUESTIONS/PURPOSES

(1) Will the manner in which information is presented to a simulated patient, in the setting of treatment for a bone sarcoma, bias their decision regarding pursuing amputation versus limb salvage? (2) At the time of decision-making, will a simulated patient's personal background, demographics, or mood affect their ultimate decision?

METHODS

Survey respondents (Amazon MTurk platform) were presented with mock clinical vignettes simulating a sarcoma diagnosis and were asked to choose between amputation and limb salvage. Specific iterations were designed to assess several described types of cognitive bias. These scenarios were distributed, using anonymous online surveys, to potential participants aged 18 years or older. Recruitment was geographically restricted to individuals in the United States. Overall, 404 respondents completed the survey. The average age of respondents was 33 years (SD 1.2 years), 60% were male and 40% were female. In all, 12% of respondents worked in healthcare. Each respondent also completed questions regarding his or her demographics and his or her current mood. Associations between the type of bias presented and the respondent's choice of limb salvage versus amputation were examined. Independent sample t-tests were used to compare means. Statistical significance was defined as p < 0.05.

RESULTS

When amputation was presented as an option to mitigate functional loss (framing bias), more patients chose it than when limb salvage was presented as means for increased functional gains (23% [23 of 100] versus 10% [12 of 118], odds ratio [OR], 2.26; p = 0.010). Older simulated patients were more likely to choose limb salvage when exposed to framing bias versus younger patients (mean age 33 years versus 30 years, p = 0.02). Respondents who were employed in healthcare more commonly chose amputation versus limb salvage when exposed to framing bias (24% [eight of 35] versus 9% [17 of 183]; OR, 2.46; p = 0.02). Those who chose amputation were more likely to score higher on scales that measured depression or negative affect.

CONCLUSIONS

Shared decision-making in orthopaedic oncology represents a unique circumstance in which several variables may influence a patient's decision between limb salvage and amputation. Invoking cognitive bias in simulated patients appeared to affect treatment decisions. We cannot be sure that these findings translate to the experience of actual sarcoma patients; however, we can conclude that important treatment decisions may be affected by cognitive bias and that patient characteristics (in this study, age, healthcare profession, and mood) may be associated with an individual's susceptibility to cognitive bias. We hope these observations will assist providers in the thoughtful delivery of highly charged information to patients facing difficult decisions, and promote further study of this important concept.

LEVEL OF EVIDENCE

Level III, economic and decision analyses.

Psychosocial reactions to upper extremity limb salvage: A case series

STUDY DESIGN

Case series.

INTRODUCTION

A salvaged limb is one that has undergone a major traumatic injury, followed by repeated surgical attempts in order to avoid amputation. Psychological recovery for individuals with lower extremity limb salvage has been examined in a number of studies. However, psychosocial reactions for individuals with upper extremity (UE) limb salvage are understudied in the literature.

PURPOSE OF THE STUDY

The purpose of this study was to explore the process of psychosocial adaptation for 3 trauma cases after UE limb salvage.

METHODS

The Reactions to Impairment and Disability Inventory was used to assess psychosocial adaptation. Physical function outcomes (pain, range of motion, edema, sensation, and dexterity) are presented. The Disabilities of the Arm, Shoulder, and Hand measure was used to assess perceived disability. Medical and rehabilitation history are discussed for each case, in order to provide in-depth understanding of the impact of these injuries.

RESULTS

Reactions to injury varied across the cases; however, outcomes suggest that psychosocial adaptation may be influenced by the experience of pain, the ability to participate in valued roles and activities, and having a supportive social network.

DISCUSSION

For this population, therapists may consider emphasizing pain management, focusing on client-centered goals and interventions, and facilitating peer support. Providers should closely monitor patients for signs of poor adaptation, such as hand-hiding behaviors.

CONCLUSIONS

This study is among the first to examine psychological outcomes for the UE limb salvage population. Future research would be beneficial to provide deeper understanding of the psychosocial challenges for these individuals.

Psychosocial reactions to upper extremity limb salvage: A cross-sectional study

STUDY DESIGN

Descriptive cross-sectional survey study.

INTRODUCTION

Limb salvage spares an extremity at risk for amputation after a major traumatic injury. Psychosocial recovery for individuals with lower extremity limb salvage has been discussed in the literature. However, to date, psychosocial reactions for individuals with upper extremity (UE) limb salvage have not been examined.

PURPOSE OF THE STUDY

To determine which factors may influence psychosocial adaptation to UE limb salvage.

METHODS

Participants (n = 30; 28 males) were adults (mean, 30.13; range, 18-61) who sustained an UE limb salvage from a traumatic event. Adaptation was measured using a modified version of the Reactions to Impairment and Disability Inventory.

RESULTS

A linear mixed-effects regression found that worse psychosocial adaptation was associated with having less than a college degree, being less than 6 months post-injury, being older than 23 years, and having more pain. Dominant hand injuries were found to influence poor adaptation on the denial Reactions to Impairment and Disability Inventory subscale only.

DISCUSSION

The results of this study indicate that there is potential for nonadaptive reactions and psychological distress with certain variables in UE limb salvage. Therapists may use these results to anticipate which clients may be at risk for poor psychosocial outcomes.

CONCLUSIONS

This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. However, future research is indicated to better understand the unique psychosocial challenges and needs of these individuals.

LEVEL OF EVIDENCE

4.

Identifying obstacles to return to duty in severely injured combat-related servicemembers with amputation

The capacity of servicemembers with amputation to return to duty after combat-related amputation and the associated disabilities remains largely unknown. The purpose of this study was to examine the disabling conditions and return to duty rates of servicemembers with amputation across all service branches following major limb amputations from September 2001 through July 2011. Pertinent medical information, military occupation status, return to duty designation, disabling conditions, and disability ratings for each servicemember were obtained from the Physical Evaluation Board Liaison Office (PEBLO). Across all service branches, 16 (2%) servicemembers were found fit for duty (Fit) and allowed to continue with their preinjury occupation. Another 103 (11%) were allowed to continue on Active Duty (COAD) in a less physically demanding role. More than half (554, 56%) were determined fully disabled (PEBLO rating > 75); the average disability rating was 73. COAD and Fit Army servicemembers had lower Injury Severity Scores than other servicemembers (17.4, p = 0.009 and 11.2, p < 0.001, respectively). Despite improvements in their care and rehabilitation, only 13% of all servicemembers with amputation are able to return to Active Duty and many have multiple disabling conditions that contribute to a very high level of disability.

Patient Use of Cost and Quality Data When Choosing a Joint Replacement Provider in the Context of Reference Pricing

Health plans are encouraging consumerism among joint replacement patients by reporting information on hospital costs and quality. Little is known about how the proliferation of such initiatives impacts patients’ selection of a surgeon and hospital. We performed a qualitative analysis of semistructured interviews with 13 patients who recently received a hip or knee replacement surgery. Patients focused on the choice of a surgeon as opposed to a hospital, and the surgeon choice was primarily made based on reputation. Most patients had long-standing relationships with an orthopedic surgeon and tended to stay with that surgeon for their replacement. Despite growing availability of cost and quality information, patients almost never used such information to make a decision.

Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I

BACKGROUND

Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.

METHODS

We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.

RESULTS

Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.

CONCLUSIONS

Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families: a qualitative study

BACKGROUND

Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process.

METHODS

Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data.

RESULTS

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics.

CONCLUSIONS

There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.