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Decision Aid for Trapeziometacarpal Arthritis Reduces Patient Decision Conflict

Key findings

  • In this randomized trial, patients who reviewed a decision aid prior to the hand surgeon appointment rather than a brochure had significantly less decision conflict at the end of the visit
  • Patients expressed mild to moderate decision regret after their initial visit regardless of group assignment
  • The use of the decision aid did not prolong consultation time or reduce patient satisfaction with the office visit

Decision aids differ from publicly disseminated information about a medical condition. They are specifically designed to increase a patient's participation in the decision-making process and to reduce decision conflict. According to previous research, decision conflict is associated with greater insecurity, delays in decision-making and lower confidence in the ultimate decision.

Patients with trapeziometacarpal (TMC) arthritis have five basic treatment choices:

  • Observation and adaption
  • Pain medication
  • Injection
  • Orthosis
  • Surgery

It can be confusing to a patient which treatment is the best option. Considering the recent emphasis on shared decision-making, it is worth investigating whether decision aids can reduce patients' uncertainty about which option to choose.

Interim Chief of the Hand & Arm Center, Neal C. Chen, MD, and colleagues at Massachusetts General Hospital have developed a web-based, interactive decision aid for TMC arthritis that patients complete in the office waiting room. In a randomized, controlled trial, they found that patients who reviewed the decision aid had less decisional conflict at the end of the visit than patients who read a brochure.

The decision aid provides an overview of TMC arthritis and its most common treatment options, emphasizing their advantages and disadvantages. It provides probabilities of various outcomes while acknowledging areas of uncertainty. A short quiz addresses common misconceptions. The aid also includes a slider instrument that helps patients clarify their values. It takes about 15 to 20 minutes to complete.

Study participants included 102 adults who were seeing a hand surgeon for the first time to discuss TMC arthritis between June 2016 and May 2017. They were randomly assigned to usual care (reading a brochure prepared by the American Society for Surgery of the Hand) or to use the decision aid. Twelve patients were later excluded because the surgeon made a diagnosis other than TMC arthritis. Follow-up questionnaires were sent by email at six weeks and six months.

The primary outcome measure was the Decisional Conflict Scale (DCS), which measures patients' perception of uncertainty in making health-related decisions. The total score ranges from 0 (no conflict) to 100. Compared with the usual care group, patients who reviewed the decision aid prior to visiting their surgeon reported significantly less decision conflict at the end of the visit. The DCS scores were 17 and 9.3, respectively (95% CI, −13 to −2.6; = .004).

Both groups experienced mild to moderate decision regret, which was measured immediately after the visit on a standardized scale. The use of the decision aid did not influence consultation time, satisfaction with the visit or perceived physician empathy.

Six patients chose surgery at the initial visit, and five chose surgery within six months for a total of 13%. Of the patients who initially chose nonsurgical treatment, typically an orthosis, most stayed with their initial decision (97% at six weeks and 91% at six months). With regard to satisfaction with treatment, there was no significant difference between the surgery and nonsurgery groups at six weeks or six months.

The researchers emphasize that because they evaluated first-time consultations, most patients had not had prior treatment. Most surgeons generally offer nonsurgical treatment to such patients, they say, but of the six surgeons participating in this study, two never specifically offer surgery for TMC arthritis at the first visit, whereas two routinely offer surgery upfront. Thus, the findings may not be generalizable to other practice situations.

That situation illustrates one of the most important goals of a decision aid: to make sure treatment decisions reflect patient values and are not based on the preferences, incentives or biases of the surgeon.

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