by Elizabeth Hofheinz, M.P.H., M.Ed., October 11, 2019
In examining 1,220 pre-visit and 967 post-visit surveys, a team of researchers has found that surgeons using patient decision aids (DAs) reported high satisfaction and no additional time needed to use this tool. Their work, “Decision Support Strategies for Hip and Knee Osteoarthritis: Less Is More,” appears in the September 18, 2019 edition of The Journal of Bone and Joint Surgery.
But why OA?
Lead author Karen Sepucha, Ph.D. is Associate Professor of Medicine at Harvard Medical School and Director of the Health Decision Sciences Center at Massachusetts General Hospital. Asked why OA was selected, Dr. Sepucha told OSN, “OA is a great clinical context for studying shared decision making and patient decision aids. OA is a common disease, and the decision about total joint replacement can be difficult. Whether or not to have surgery depends not only on clinical features, but also on patients’ goals and preferences. There are existing studies of DAs that have demonstrated significant improvements over usual care in OA, but there was little or no guidance on which of the available DAs work best. The study was designed to fill that gap in the literature.”
The team used a long, detailed DA as well as a short, interactive DA. Eight surgeons were randomly selected to either proceed with usual care or to receive a patient preference report containing information on the patient’s goals and treatment preferences.
And how were the decision aids selected?
Dr. Sepucha notes, “The Health Dialog decision aids have been studied in several randomized trials and have been shown to significantly improve the quality of decisions compared to usual care. These tools are really the gold standard in the field. Massachusetts General Hospital had a longstanding relationship with Health Dialog and had been using their decision aids in orthopedics as well as other areas for several years. The Healthwise decision aids were selected as a comparator because they took a different approach to informing and engaging patients, e.g. focusing on key facts and using quizzes to ensure users understand the important information.”
Key findings…
“Both tools performed well at these sites and resulted in a high percentage of patients making informed decisions. Some of the key findings were that (1) the shorter DA resulted in higher knowledge scores (contrary to our hypothesis) (2) surgeons did not perceive any increase in visit length when patients got DAs as part of care, and (3) in this sample, the majority of patients went on to have surgery. Many surgeons are wary of using DAs or engaging patients in shared decision making for fear that it will take too much time and reduce surgical rates—neither of which was supported by evidence in this study.”
First listen…then listen again…
Co-author Andrew Freiberg, M.D., who led the hip and knee service at Massachusetts General Hospital for over 20 years, told OSN, “The DAs are very helpful informing patients about the different treatments and potential outcomes. As our patient advisors emphasized to us, it is equally important that surgeons listen to and tailor recommendations to patients’ preferences. The surgeon intervention that we tested (the Patient Preference Report) was an attempt to explicitly incorporate patients’ goals and preferences into the discussion; however, we did not find any impact on study outcomes. About 25% of patients did not receive their preferred treatment, and it would be important to figure out how to make sure that more people receive their preferred treatment.”
Dr. Freiberg, now the Chief Medical Officer at Zimmer Biomet, commented to OSN, “Patients with hip and knee OA are highly motivated to use the information provided in advance of a visit with the surgeon. High quality decision aids can help patients prepare for visits and be more informed about the options, risks and benefits. Surgeons really benefit from the shared decision process in that patients are better informed and are more active in decision making and taking ownership or their recovery.”
