Aligning Surgical Decisions With Older Adults' Outcome Goals

Decision-making for surgery and procedures is challenging for older adults with multiple chronic conditions (MCCs) due to uncertain benefits and heightened risks. These individuals vary in the health outcomes they desire most [1], necessitating discussions that go beyond ‘fixing’ a clinical problem. However, intervention decisions usually do not consider the likelihood of achieving patient-identified outcome goals [2]. Traditional decision aids provide information on treatment options [3], but do not address personal goals or assess whether a procedure aligns with them. Effective decision-making for older adults with MCCs requires tools that help patients identify specific, realistic, and actionable goals [4]. The Patient Priorities Care (PPC) approach has been successful in reducing treatment burden and improving alignment with patient priorities in managing chronic conditions [5]. This study adapts PPC principles for discrete intervention decisions by developing a tool that can be completed with clinician guidance or self-directed with probes. The completed tool can facilitate patient-interventionalist discussions around whether interventions align with patient-specific outcome goals and health priorities [5]. Five clinical experts, including geriatricians, surgeons, and interventionalists, met monthly for 4 months to create a goals-aligned decision tool. A user-centered design framework [6] guided development, with clinician expert input on key domains and usability considerations. We obtained feedback from two groups: First, 7 older participants with MCCs who recently underwent revascularization for peripheral arterial disease reviewed the tool. Using “think-aloud” methodology, they provided real-time feedback on comprehension and usability. Second, 9 members of a community scientist program reviewed the tool via a Zoom session and shared insights based on their experiences. Feedback from both groups was categorized into key themes and used to refine the tool, focusing on improved communication, patient empowerment, and conciseness. This study was approved by UTHealth Committee for the Protection of Human Subjects (IRB HSC-SPH-22-0586). Patients who underwent revascularization (65–81 years old and 43% female) reported goals such as regaining mobility, reducing pain, returning to activities like hiking, and improving independence. All participants found the tool's questions relevant and believed it facilitated meaningful discussions with clinicians, particularly their fears and goals (Table 1). They suggested simplifying the tool for ease of use. Based on feedback, the revised tool (Figure 1) includes a table with broad goal categories to guide goal identification and specification, and discussion prompts for interventionalists about alignment with the patient's outcome goal and procedure-specific tradeoffs. The Patient Priorities-Aligned Intervention Decisions (PPAID) tool was developed through an iterative process incorporating clinician expert and patient input. Unlike traditional decision aids [3], PPAID centers discussions on outcome goals rather than procedural choices, ensuring decisions align with patient-specific goals [5]. The PPAID tool builds on the innovative work by Schwarze et al. [2] who identified four recurring goal categories that broadly capture the outcomes that patients desire from surgery. These categorical goals anchor subsequent deliberations, resulting in the identification of a specific and realistic outcome goal for the given discrete intervention [2]. Future research will evaluate tool feasibility, acceptability, and effectiveness in clinical settings with various procedures. Metrics will include pre-procedure goal agreement, decision regret, and patient satisfaction. Integrating the tool into clinical workflows is crucial for its adoption. The PPAID tool offers a structured approach to patient-centered decision-making for discrete interventions. By emphasizing goal identification and deliberation, it supports age-friendly, patient goals-aligned care as required by the new CMS age-friendly measure [7]. Aanand D. Naik: resources, concept, design, data analysis, supervision, wrote manuscript. Margaret L. Schwarze: concept, reviewed manuscript. Jack Banks: project management, data collection, data analysis, reviewed manuscript. Suha Soni: project management, data collection, reviewed manuscript. Salman A. Arain: concept, reviewed manuscript. Parag Goyal: concept, reviewed manuscript. Daniel D. Matlock: concept, reviewed manuscript. Rachel Lampert: concept, reviewed manuscript. Mary E. Tinetti: concept, design, supervision, reviewed manuscript. All authors of this manuscript have met the Uniform Requirements for Authorship, in that we have (1) made substantial contributions to conception, design, acquisition of data, or analysis and interpretation of data; (2) drafted or revised the manuscript for important intellectual content; and (3) read and approved this submission. The sponsor had no role in the design or implementation of the study. The authors declare no conflicts of interest.