Invited commentary

Abstract

The authors are to be commended for applying decision analysis to the vexing problem of how to measure the efficacy of treatment for symptomatic lower extremity atherosclerosis and for the choice to include in this analysis the majority of such patients—those with milder symptoms. Despite the limited data available to calibrate the outcome-based probability parameters, the authors’ model was fairly accurate in predicting the quality of life (QOL) and walking status of patients at 1 year. The truly disappointing findings were the actual QOL data: (1) significant benefit was noted only for those with the most severe disease who had surgical intervention and (2) medical therapy had no impact on QOL metrics. While one can quibble about whether other QOL questionnaires may have shown different results in this cohort, the data are sobering. Data like these have led health care payers, regulatory agencies, and patients themselves to question the efficacy of management approaches crafted over decades by vascular specialists. They also challenge our claim to superior knowledge and expertise in this arena. How should vascular surgeons respond? First, we must accept that our traditional objective end points of patency, ankle pressure, and rates of limb salvage and survival may not capture the outcomes most important to our patients, especially those with mild disease. Second, we must be committed to prospective analysis of outcomes of our patients with lower extremity atherosclerosis across the full spectrum of disease and apply the most modern methods of analysis to this task. The authors point out that better risk-adjusted outcomes data are needed to more accurately calibrate models such as theirs. It may be that accurate prospective QOL data on percutaneous treatments will provide a valid rationale for the application of these techniques to subsets of patients with earlier stages of disease. Third, we must take an active role in the development and testing of new methods of treatment for patients with mild disease. The ineffectiveness of current noninterventional therapy from the patient’s perspective is clear from this study. Finally, vascular surgeons must be open to the idea of incorporating data from a model such as this into actual clinical decision making. Such an application is premature at this point, but data-driven management protocols or guidelines are on the way, and vascular experts must contribute fundamentally to their development for the benefit of both our patients and our specialty. Prospective decision analysis for peripheral vascular disease predicts future quality of lifeJournal of Vascular SurgeryVol. 46Issue 4PreviewDecision 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. Full-Text PDF Open Archive