Heterogeneity of Patients’ Preferences for Bone-Anchored Prostheses After Lower-Extremity Amputation (PREFER-BAP-2)

BACKGROUND: Patients with a bone-anchored prosthesis (BAP) previously expressed preferences regarding (i.e., indicated the importance of) 5 treatment attributes: change in quality of life (QoL), short- and long-term complications, implant survival, and out-of-pocket contributions (costs). However, preference heterogeneity is unclear. We aimed to identify latent preference subgroups, quantify attribute importance per subgroup, and describe background characteristics associated with each subgroup. METHODS: A discrete choice experiment to reveal preferences for BAP characteristics among 247 patients from The Netherlands was analyzed using a latent class logit model. Subgroups (classes) were interpreted using relative attribute weights and patient characteristics. RESULTS: A model with 3 classes (with 49% [n = 121], 27% [n = 67], and 24% [n = 59] of the patients in Classes 1, 2, and 3, respectively) fit best. Across classes, short-term complications were least important, and patients considered opting out of BAP treatment when outcomes were unfavorable. Within the classes, when BAP was selected, QoL remained a key driver (31% of decision weight in Class 1, 53% in Class 2, and 26% in Class 3). Class 1 weighted QoL and out-of-pocket contributions most; Class 2 prioritized QoL and disregarded short-term complications; Class 3 placed the most weight on long-term complications and was sensitive to out-of-pocket contributions mainly at high cost levels (€20,000 to €25,000) and to osseointegrated implant survival only when survival dropped from 20 to 5 years. Background profiles differed: compared with the other classes, Class 1 (66% male) had a greater proportion of patients with transtibial amputations and longer BAP experience; Class 2 (48% male) included a greater proportion with higher education and income levels and worse pre-treatment mobility, pain, and anxiety; and Class 3 (80% male) had a greater proportion with lower education and income levels, and the highest proportion awaiting surgery. CONCLUSIONS: Patient preferences for key aspects of BAP treatment are heterogeneous. We identified 3 distinct subgroups, and a patient's background characteristics can help estimate membership in a particular subgroup. Patient-reported outcomes should be interpreted in light of these preference differences. Future work should integrate preference assessment into pre-treatment triage to better align counseling and selection with what patients value, ideally using a brief choice-task screening tool; the optimal screening tasks remain to be established. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.