Nobody is suggesting that prosthetic research is broken. There’s too much progress taking place for that description to fit. Every year brings new breakthroughs in powered legs, dexterous hands, neuroprosthetics, smart sockets, and so forth. But there’s an obvious disconnect in translating those laboratory triumphs into widely shared wins for the limb-loss community. Innovations seemingly take forever to advance from the testing phase to the commercial market. And when they finally do get into general circulation, other barriers—including high costs, steep learning curves, bureaucratic obstacles, and spotty on-boarding of healthcare clinicians—often limit the impact of these technological marvels on amputees’ day-to-day lives. The lucky few who have great insurance and creative prosthetists reap the full benefits; everyone else either can’t get next-gen devices at all, or can’t use them to their fullest extent.
Solving those problems doesn’t begin after new technologies exit the R&D phase. Solutions can, and must, be part of the design process itself. That’s the argument set forth in a new paper published in Frontiers in Rehabilitation Sciences. Written by a group of prosthetic researchers, clinicians, and educators from the Baylor College of Medicine and the University of Washington, the article lays out specific guidelines for the research community that are aimed at improving the implementation of new products, enabling more people to get more benefit.
We’ve summarized some of the key recommendations below, and they’re not staggeringly complex. These are common-sense reforms that wouldn’t require vast amounts of time and money to implement. All that’s needed is more careful communication, broader collaboration, and a slightly more patient-centered mindset. Read the full paper at this link.
1. Encourage patient autonomy
This is one of the last recommendations in the paper, but we think it’s the most crucial so we’re placing it first. When new products come out, attention understandably centers on their splashiest technological and functional features—the first-ever, best-ever stuff that gets everyone excited. But those breathless promos often crowd out other information that patients need in order to make fully informed, holistic decisions about their prosthetic care. “Complete transparency about the design process, intended functionality, benefits and drawbacks, costs, and maintenance requirements for prosthetic devices should always be conveyed by researchers,” the authors write. Moreover, clinicians need to make a stronger effort to translate those complexities to their patients, so patients can participate in decisions regarding their own care: “Shared decision-making models help clinicians improve communication, understand patient values, utilize their clinical experience, and clarify the prosthetic journey for the patient.” Amen.
2. Practice user-centered design
“User-centered design . . . is the process in which developers include the needs, values, opinions, and concerns of end-users throughout the design and implementation of a novel idea or product,” the authors assert. Duh, right? The authors go on to describe user-centered design as “a shift from thinking of people as ‘end-users’ towards integrating them as equal members of the team developing the technology (i.e., making technology with people instead of for them) [emphasis added].” Failure to do so, they note, can (and does) result in products that aren’t useful—no matter how advanced they may be technologically—because they’re uncomfortable, ugly, ill-fitting, impossible to master, or otherwise impractical. User-centered design isn’t anything particularly radical; the authors cite two well-tested frameworks (Technology Acceptance Model and the Usability Metric for User Experience) that have proven track records.
3. Include clinician perspectives
The authors also argue that “prosthetic device development should involve the perspectives of the clinicians (e.g., prosthetists, physical therapists, occupational therapists, and others) who are members of the interprofessional healthcare team.” Hard to believe this doesn’t happen every single time, eh? To be fair, most researchers do consult with clinicians. They just don’t always ask all the right questions. Clinicians’ input is rarely sought on non-technical considerations such as patient education, rehabilitation guidelines, varying comfort levels with technology, motivation, mental health, and other factors. Yet these can be just as important to a new device’s uptake as its function and performance. Addressing those sorts of issues on the front end can yield more amputee-friendly prosetheses on the back end.
4. Understand patient insurance and clinician reimbursement
We get why researchers might overlook these factors. Nobody wants to think about them, because they’re ridiculously complex and illogical (as we describe in our new print edition). Yet this is, as the authors assert, “arguably the most critical aspect of technology translation into prosthetic patient care.” They go on to list multiple issues that affect the coverage/reimbursement algorithm, including the need to document (via extensive, high-quality evidence) a device’s specific health benefit(s); the unrecognized (and therefore uncovered) aesthetic and mental-health benefits of prosthetic technology; and the invisible costs imposed by devices with heavy maintenance burdens, which prosthetists must bear in the form of uncompensated time/effort, and patients must bear in device downtime, more frequent clinic visits, and so forth. Ultimately, the paper concludes, “it is important to keep these funding structures in mind during the development of new prosthetic technology [emphasis added].”
5. Promote health equity
Prosthetic care is no different from any other aspect of the US healthcare system: Those at the very top of the socioeconomic spectrum get the most access to the best technologies, while the middle and lower tiers have to make do with less effective solutions. “Advanced prosthetic technology could continue to widen these existing health disparities,” the authors observe. “People who are older adults, belong to systematically marginalized groups, or live in rural communities are often underrepresented in prosthetics literature, including technology development.” Technological literacy is itself unevenly distributed, yet most devices assume that users will be comfortable with and adept at advanced tech. Researchers can partially mitigate these demographic patterns by pursuing solutions targeted at populations who are currently underserved, and by more aggressively recruiting individuals from those populations to participate in focus groups, design teams, and clinical trials.