The VHA AMPREDICT Decision Support Tool: Translating Success to Point of Care

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Amputation level decision making in patients with chronic limb threatening ischemia (CLTI) is challenging. The choice of amputation level in this population can profoundly affect risk of operative mortality, re-hospitalization, reamputation, functional mobility, and ultimately quality of life. One of the most important factors influencing the amputation level decision is the preservation of mobility because of its association with quality of life. However, the potential mobility benefits of more distal amputations may not be realized because of the increased risk of compromised healing, need for ongoing wound care, and ultimately reamputation to a higher level. An additional factor critical in decision making in this population is a mortality risk which is higher than the majority of cancer diagnoses. This limited survival creates an imperative for both surgeon and patient to make decisions that will best ensure the patient’s remaining life years conform to their values and priorities. Veteran Health Administration data suggest that between 2005-2014, the proportion of incident transmetatarsal (TM) amputations tripled from 10% to 30% of all CLTI amputations with a corresponding decrease in the proportion of transtibial (TT) and transfemoral (TF) amputations. The increase in TM amputations may be driven by the improvement in revascularizations, greater teamwork, and the assumption that preserving the ankle joint will enable superior mobility; however, it is unclear how the risks of not healing are considered in the decision. Balancing these risks is at the core of a complex shared decision-making (SDM) process between physicians and patients as they determine the “best” level of amputation. An important resource that enables successful implementation of SDM are clinical decision support tools (DSTs). They provide clinicians with patient specific risks for key outcomes in real time. To equip physicians with such a tool, we leveraged our prior prediction models to create the AMPREDICT DST. It is an online DST that includes a home page, predictor pages, and a result page with patient specific one-year mortality and reamputation risks and probability of achieving a basic level of independent mobility, at each of three amputation levels (TM TT, TF). It has undergone successful testing by VHA physicians nationwide. The successful implementation of the DST in clinical care requires buy in from user groups as well as the need to overcome potential implementation obstacles. Our evaluation of the DST in physician users has provided important insights that will be addressed in the current proposal. Many of the providers discussed the importance of DST integration into the EHR with auto-population of the predictors to minimize the implementation burden. Further, vascular surgeons recommended considering additional vascular diagnostic and therapeutic predictors that are viewed as important in the clinical decisional process, in the prediction models. This is supported by cutting edge developments in the recent literature. The goals of this grant are therefore threefold. First, we will enhance the quality of the AMPREDICT prediction models in a more contemporary population by replacing predictors not readily available in the EHR with similar predictors that are available, and the evaluation of additional vascular predictors. We will accomplish this through a systemic development process considering demographics, social support, comorbidities, health factors, prior vascular procedures, laboratory values, medications, and mental health predictors available in the EHR just prior to the amputation. Second, we will perform the necessary planning and programming to integrate the enhanced AMPREDICT DST into the VHA EHR to facilitate the auto-population through CPRS and Cerner. This will be accomplished through collaborating with the Amputee System of Care joint Cerner workgroup and collaborating with a firm with significant experience implementing risk calculators within the VHA EHR. Third, we will evaluate the usability and effect of the enhanced DST within the EHR on physician and patient decisional conflict, patient decisional regret and satisfaction. [Semi- structured qualitative interviews of surgeons will evaluate clinical/institutional factors that affect implementation.] Together this will result in an important clinical advancement in one of the most life changing clinical decisions.