title: Prospective decision analysis modeling indicates that clinical decisions in vascular surgery often fail to maximize patient expected utility.
abstract: BACKGROUND
  Applied prospectively to patients with peripheral arterial disease, individualized decision analysis has the potential to improve the surgeon's ability to optimize patient outcome.
  
  
  METHODS
  A prospective, randomized trial comparing Markov surgical decision analysis to standard decision-making was performed in 206 patients with symptomatic lower extremity arterial disease. Utility assessment and quality of life were determined from individual patients prior to treatment. Vascular surgeons provided estimates of probability of treatment outcome, intended and actual treatment plans, and assessment of comfort with the decision (PDPI). Treatment plans and PDPI evaluations were repeated after each surgeon was made aware of model predictions for half of the patients in a randomized manner.
  
  
  RESULTS
  Optimal treatments predicted by decision analysis differed significantly from the surgeon's initial plan and consisted of bypass for 30 versus 29%, respectively, angioplasty for 28 versus 11%, amputation for 31 versus 6%, and medical management for 34 versus 54% (agreement 50%, kappa 0.28). Surgeon awareness of the decision model results did not alter the verbalized final plan, but did trend toward less frequent use of bypass. Patients for whom the model agreed with the surgeon's initial plan were less likely to undergo bypass (13 versus 30%, P < 0.01). Greater surgeon comfort was present when the initial plan and model agreed (PDPI score 47.5 versus 45.6, P < 0.005).
  
  
  CONCLUSIONS
  Individualized application of a decision model to patients with peripheral arterial disease suggests that arterial bypass is frequently recommended even when it may not maximize patient expected utility.
authors.affiliation: Medical University of South Carolina and Ralph H. Johnson Department of Veterans Affairs Medical Center, 96 Jonathan Lucas Street, PO Box 250614, Suite 424, Charleston, SC 29425, USA. brothete@musc.edu
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Brothers
authors.forename: Montgomery H
authors.initials: MH
authors.lastname: Cox
authors.forename: Jacob G
authors.initials: JG
authors.lastname: Robison
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Elliott
authors.forename: Paul
authors.initials: P
authors.lastname: Nietert
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D017130:Angioplasty; D001158:Arteries; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D006801:Humans; D007866:Leg / Q000098:blood supply; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D010347:Patient Care Planning; D017060:Patient Satisfaction; D011788:Quality of Life; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000601:surgery* / Q000628:therapy; D014656:Vascular Surgical Procedures