
If I offered you the opportunity to trade your current car in for either a used minivan or the newest sports car on the market, which would you choose?
While the sports car might be an obvious choice for many of you, let’s pause for a moment to consider the pros and cons of this decision. If you value aesthetics, the sports car may be the winner. However, what about the cost? Are you concerned about how much you will spend on gas and monthly maintenance? In that case, the minivan, which offers better fuel efficiency and more affordable repairs may be more attractive. While the cost alone might not deter you from choosing the beautiful sports car, size and safety are important factors to consider (especially if you have a large family), making the minivan a more suitable choice. Nevertheless, the minivan does come with its own challenges. As a used vehicle, it may have higher mileage, and you might be unaware of any previous issues, which could mean lacking the peace of mind that a brand-new sports car would provide.
After all factors are considered, those who prioritize comfort, safety, and affordability may find the minivan to be the best option. Conversely, those who value aesthetics, cutting-edge technology, and the reassurance of a car still under warranty might lean toward the sports car. Ultimately, making this decision requires weighing the significance of various aspects to decide what matters most to you.
Thoughtful decision-making is an intricate process that requires an understanding of one’s own preferences and needs, as well as knowledge about the pros and cons of each option. For individuals with upper-limb loss or limb difference, selecting and using a prosthetic device is a significant decision that impacts many aspects of their daily lives. While it is well known that using a prosthesis improves functional mobility and quality of life for people with upper-limb loss, there is less information available to understand patient preferences and guide users in the selection process of their prostheses.1-3 This can lead patients to make choices that might not best align with their preferences, which could contribute to the high discontinuation rates of upper-limb prostheses.4-5 Therefore, it is crucial for both patients and clinicians to be well equipped to select devices that align best with patients’ needs and lifestyles. Additionally, it is important for manufacturers and policymakers to recognize the factors informing patient preferences to guide the development of new technologies and policies—ultimately enhancing access to devices that best meet patients’ individual needs.
Choice-based Conjoint Methodology: Putting the Patient in the Driver’s Seat
While patients’ preferences are crucial for decision-making, patients are sometimes unclear about which prosthetic factors are important to them. Research and clinical education play a vital role in bridging this gap. Choice-based conjoint methodology is a research technique used to understand choices and how people value certain attributes.6 Using this technique, researchers can gather data from a representative sample of patients to determine which attributes matter most to them, rank these attributes based on their level of importance, and measure the trade-off between the pros and cons of each attribute.

For example, in the context of choosing between a sports car and a minivan, choice-based conjoint methodology could help determine if vehicle storage space is a significant factor valued by most car buyers. It could also help rank the importance of storage space compared to other vehicle traits such as cost and aesthetics. The technique also allows researchers to identify which other vehicle features buyers are willing to sacrifice to maintain a good amount of storage space. Similarly, for an upper-limb prosthesis, this methodology could reveal how much a person values a lighter weight device versus one with more aesthetic appeal.
At the individual patient level, having this information can improve patient-prosthetist communication by supporting shared decision-making, allowing the patient and clinician to work together to make choices that align with the patient’s functional needs and values.7 When patients go through the process of weighing different prosthesis attributes, such as aesthetics or amount of training required, it can empower them to confidently work with their clinicians to select a device that is appropriate for their needs. These preferences can then be incorporated into the clinical care plan. Furthermore, effectively discussing and documenting patient preferences can allow clinicians to track changes in patients’ needs as their experience and life situations evolve, ensuring their needs are best met throughout their lifetimes.
On a larger scale, incorporating patient preferences in prosthesis selection can better inform healthcare policy. As our healthcare system shifts gears toward value-based care, there is an increased need for outcomes. By including the patients’ experience into clinical care, patients have a stronger voice in determining the device that will best meet their needs, leading to greater utilization, and ultimately leading to better clinical outcomes. This results in an overall increase in the quality of care provided by clinicians.8
Finally, having knowledge about patient prosthetic preferences can have a broad effect on the greater prosthetics profession. Understanding what patients prefer could motivate manufacturers and innovators to create prosthetic devices that better align with patient needs.
Taking Patient Preferences for a Test Drive
Funded by the Congressionally Directed Medical Research Programs-Orthotics and Prosthetics Outcomes Research Program, the University of California, San Francisco, and the Hanger Institute for Clinical Research and Education have been tasked to develop and test a shared decision-making tool using choice-based conjoint methodology for patient preferences. This project aims to further the understanding of the benefits and trade-offs a person considers when choosing an upper-limb prosthesis and to create a decision-aiding tool to enhance prosthetic prescriptions.
Creating this decision-aiding tool has involved a rigorous process to ensure its soundness and inclusivity of the voices of patients, clinicians, and other stakeholders. Initially, a systematic review of the literature was conducted to investigate which prosthetic factors previous research identified as important to patients. This review yielded 67 studies that investigated patient satisfaction, quality of life, cost, and prosthesis characteristics, from which a total of 109 attributes were identified as relevant to the decision-making process for choosing an upper-limb prosthesis.

Next, cognitive interviews with a representative group of patients were conducted using open-ended questions to determine if the factors identified from the literature review were truly important to patients and to identify any new factors that might not have been included in the review. This process narrowed down the 109 factors to 11. These 11 factors were then reviewed by the project’s advisory board, composed of experts in upper-limb care, patient advocacy groups, and patient experience. They further refined these attributes to clarify their meanings and reduced the total from 11 to eight. The final list of attributes is as follows:
- Functional usefulness of the device
- Device weight, comfort experience
- Durability, repair times
- Amount of concentration and energy to use the device, even with training
- Connection of the arm to the body
- Physical training and practice for successful use of the device
- Life goals for using two hands, including the device
- Noticeability of the device
Using this information, two questionnaires were developed. One of these questionnaires considers all the aforementioned factors plus the cost constraints of each factor. The second questionnaire considers all the factors without cost constraints to better understand what matters most to patients.
The next step is to administer the questionnaires to a nationwide sample of more than 200 individuals with upper-limb loss. The results from this large-scale testing will allow researchers to further develop and prepare a final decision-aiding tool ready for implementation in clinical practice.
Patient Preferences: On the Road to Patient-centered Care
Once finalized, this tool will be deployed into clinical practice and will improve the quality of care by enhancing collaboration between patients and care providers. Including patient preferences in the decision-making process will allow patients to make more informed choices, which will increase patient satisfaction and reduce indecision, thereby improving device utilization and ultimately leading to better health outcomes. Additionally, this will support value-based care models by enabling prosthetists to provide clinical solutions that truly impact the areas of life most important to patients. In the long run, the data accumulated from the utilization of this model could help inform policies that influence coverage for devices that better align with patients’ needs.
Kristin E. Nalivaika, OTD, OTR/L, and Patsy M. Diaz Delgado, MS, are members of the Hanger Institute for Clinical Research and Education. Nalivaika is a research associate and an occupational therapist. Diaz Delgado is a research assistant and has a degree in dietetics and nutrition. They can be contacted at [email protected] and [email protected].
References
- Engdahl, S. M., M. A. Gonzalez, C. Lee, and D. H. Gates. 2024. Perspectives on the comparative benefits of body-powered and myoelectric upper limb prostheses. Journal of Neuroengineering and Rehabilitation 21(1):138.
- England, D. L., T. A. Miller, P. M. Stevens, J. H. Campbell, and S. R. Wurdeman. 2021. Assessment of a nine-Item Patient-Reported Outcomes Measurement Information System Upper Extremity Instrument among individuals with upper limb amputation. American Journal of Physical Medicine & Rehabilitation 100(2):130–7.
- Yamamoto, M., K. C. Chung, and J. Sterbenz, J., et al.. 2019. Cross-sectional international multicenter study on quality of life and reasons for abandonment of upper limb prostheses. Plastic and Reconstructive Surgery – Global Open 7(5):e2205.
- Østlie, K., I. M. Lesj, R. J. Franklin, B. Garfelt, O. H. Skjeldal, and P. Magnus. 2012. Prosthesis rejection in acquired major upper-limb amputees: A population-based survey. Disability & Rehabilitation: Assistive Technology 7(4):294–303.
- Salminger, S., H. Stino, H., and L. H. Pichler, L. H., et al. 2022. Current rates of prosthetic usage in upper-limb amputees – have innovations had an impact on device acceptance? Disability and Rehabilitation 44(14):3708–13.
- Chitturi, P., and A. Carides. 2020. Experimental design issues in choice-based conjoint applied to patient choice in healthcare. Journal of Comparative Effectiveness Research 9(2):141–7.
- Davidson, K. W., C. M. Mangione, and M. J. Barry, et al. 2022. Collaboration and shared decision-making between patients and clinicians in preventive health care decisions and US Preventive Services Task Force recommendations. The Journal of the Medical Association 327(12):1171–6.
- U.S. Centers for Medicare & Medicaid Services. 2024. Value-Based Care. Centers for Medicare & Medicaid Services. https://www.cms.gov/priorities/innovation/key-concepts/value-based-care