- Patients were significantly more likely to use a decision aid (DA) when it was sent before the visit with the orthopedic specialist
- DAs were significantly more likely to be sent when the entire clinic staff was involved in ordering them than when only an orthopedic specialist was responsible
- Ordering DAs via the electronic medical record was key to facilitating their delivery, including delivery to patients being referred from primary care
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Patient engagement in treatment decisions is now widely advocated and is particularly relevant for elective orthopedic surgical decisions. A recent Cochrane review documented that the use of patient decision aids (DAs) improves patient knowledge and expectations, reduces decisional conflict and boosts patient participation in care. However, few studies of DAs are specific to orthopedics, and none have examined how to implement DAs in fee-for-service practices.
Researchers at Massachusetts General Hospital undertook a quality improvement project to boost delivery of DAs in the Department of Orthopaedic Surgery. In BMJ Quality & Safety they report three keys to success:
- Clinical champions
- Effective use of information technology
- Engagement of the entire staff
The authors of the publication include Assistant Chief of the Orthopaedic Spine Center Thomas D. Cha, MD, MBA, Chief of the Center for Hip and Knee Replacement Andrew A. Freiberg, MD, Emeritus Chief of the Department of Orthopaedics Harry E. Rubash, MD and Karen R. Sepucha, PhD, director of the Health Decision Sciences Center.
The project was conducted in three phases between July 2013 and March 2015 at Mass General. Phase 1 targeted orthopedic specialists, phase 2 targeted primary care physicians and phase 3 targeted the entire orthopedics staff.
The study focused on patients with hip or knee osteoarthritis, lumbar herniated disc or lumbar spinal stenosis. The primary outcome measured was the percentage of eligible patients who received a DA during each phase. The aim was 60% for each phase.
At Mass General, a DA ordering application is embedded in the electronic medical record. Each DA contains a DVD video program and a booklet that covers the main surgical and nonsurgical treatment options. DAs are either mailed to patients or sent electronically to registered users of the hospital’s patient portal.
In phase 1, orthopedic specialists ordered DAs for only 33.9% of 463 eligible patients. This was true even though, per hospital policy on QI projects, specialists were offered a one-time monetary bonus for meeting a target of 60%. According to physician feedback, the biggest constraint was that specialists did not remember to order the DA during the visit.
Most orders by specialists, 75%, were placed on the day of the orthopedic visit. Comments from both patients and specialists suggested it would be more valuable to send the DA before the visit, and that feedback was addressed in phase 3.
In phase 2, about 57% of the 442 referrals from primary care physicians came with a request for a DA. All but 17.8% of those patients had a DA sent. Common barriers to delivery were that the patient declined an orthopedics appointment, could not be reached to schedule an appointment or was initially referred to the wrong department.
In phase 3, the researchers worked closely with the entire orthopedics staff to encourage delivery of DAs before the office visit. The target was exceeded as 64.5% of 469 eligible patients received a DA, a significant increase from phase 1. In addition, significantly more patients received the DA before the visit (73.6% for phase 3 vs. 17.4% for phase 1; P < .001).
Patients were surveyed after phases 1 and 3. Most who were sent a DA said they received it (phase 1, 87.5%; phase 3, 84.6%). About half of the patients in each phase said they reviewed all of the DVD and/or all of the booklet.
The authors note that champions of shared decision-making started the project by promoting the use of DAs to their colleagues. They conclude that other keys to implementation of DAs were effective use of information technology and engagement of the entire staff, including schedulers.
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