Development of a Multidisciplinary Decision Support Instrument for Patients With a Ruptured Abdominal Aortic Aneurysm Based on Multidisciplinary Codified Peer Expertise: A Discrete Choice Experiment.

INTRODUCTION: Treatment decisions for ruptured abdominal aortic aneurysms (rAAA) patients are made under extreme time pressure and often with limited patient information and without opportunity for multidisciplinary consultation. This study describes the development of a decision-support instrument (DSI) to predict how experts would decide in real-life emergency scenarios, based on patient characteristics including frailty, estimated life expectancy, and treatment preference.

METHODS: The DSI was developed using a discrete choice experiment. A multidisciplinary group of medical specialists, including vascular/oncological surgeons, anesthesiologists, intensivists, and geriatricians, defined the relevant criteria for deciding whether to operate on an rAAA based on patient-specific factors and expert opinion. The group identified relevant levels for each criterion, with an increasing risk for worse outcomes. Criteria that would immediately exclude a patient from treatment were designated as knockout criteria. An expert panel of 21 medical specialists evaluated 30 fictional patient scenarios, which resulted in a weight for each criterion expressed as relative importance (RI); a measure of how much each criterion, compared to the sum of all criteria, contributes to the model's outcome. The finalized DSI predicts the percentage of medical specialists who would choose to operate on a specific patient, based on the input criteria for that patient.

RESULTS: In 4 criteria sessions with medical experts, consensus was reached on 11 criteria that were judged to influence the decision whether to operate or not: cardiopulmonary resuscitation, patient's wish for operation, renal function, age, life expectancy, endovascular treatment options, hemoglobin blood concentration, mean arterial pressure, pulmonary burden, cardiac burden, and clinical frailty score. Nine criteria had a significant impact on the decision; the most significant were cardiac burden (RI, 15%), age (RI, 13%), life expectancy (RI, 13%), and Clinical Frailty Scale and pulmonary burden (both RI, 12%).

CONCLUSION: A clinical DSI was developed, based on codified multidisciplinary peer expertise, to support real-life medical decision-making during acute treatment planning for rAAA. Three parameters that are underreported in previous scoring systems (patient's frailty, estimated life expectancy, and patient's desire to be operated) were considered most important for treatment decision.Clinical ImpactTreatment decisions for ruptured abdominal aortic aneurysm patients are time-critical and morally complex, often made with limited clinical information and without multidisciplinary consultation. This study describes the development of a transparent decision-support instrument (DSI) based on multidisciplinary peer expertise. By reflecting decision logic and criteria considered important by experts, the DSI may contribute to more consistent decision-making and help identify patients for whom palliative care might be more appropriate. Further validation is required to determine its clinical utility, although this approach may support clinicians in urgent, morally complex scenarios.