Optimizing Decision Aids About Surgery for Hip or Knee Osteoarthritis

It's now established that patient decision aids (DAs) reduce decisional conflict and improve knowledge compared with usual care. The Washington State Health Care Authority recently certified DAs for treatment of hip and knee osteoarthritis, and national certification efforts are underway.

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Certified DAs vary in their amount of detail, level of interactivity and use of patient narratives, and no data are available about their comparative effectiveness. In addition, studies show that DAs have little impact on a key goal of shared decision-making: aligning the treatment choice to the patient's preference.

Karen Sepucha, PhD, director of the Health Decision Sciences Center at Massachusetts General Hospital, and Andrew A. Freiberg, MD, formerly of the Department of Orthopaedics, and colleagues conducted a multisite randomized trial that had two major findings: patients learn more from shorter, interactive DAs than longer, more detailed DAs; and having patients report their preferences to surgeons in writing does not increase the number of patients receiving their preferred treatment. These data appear in The Journal of Bone & Joint Surgery.

Study Design

The DECIDE-OA trial involved eight surgeons at three sites: Mass General, Boston, Massachusetts; Newton Wellesley Hospital, Newton, Massachusetts; and New England Baptist Hospital, Boston, Massachusetts. The surgeons were divided into two groups, with one randomly assigned to provide usual care. The surgeons in the other group received a written report from patients, before their visit, about their functional impairment, treatment preference and main goal for the visit. A sample patient preference report appears in a supplement to the journal article.

Between April 2016 and December 2017, the research team randomly assigned 1,911 patients with knee or hip osteoarthritis to receive either a short or long DA about surgery for their condition. The short DAs are online interactive tools and can be printed as 12-page brochures. The long DAs are DVDs, approximately 45 minutes long, and are also available as booklets, approximately 50 pages long.

Patients were asked to complete the short version of the Hip/Knee Osteoarthritis Decision Quality Instrument, developed at Mass General, at three time points: after they used the DA (before the surgeon visit), one week after the visit and six months after (or six months postoperatively, if they had surgery). This tool comprises five knowledge items and one question about treatment preference (surgical, nonsurgical or unsure).

The primary outcome was the informed patient-centered decision, a binary measure: the percentage of patients who had a knowledge score ≥60% and the percentage who received their preferred treatment within six months. This measure is endorsed by the National Quality Forum and has been associated with improved outcomes in orthopedics, according to a study published in Medical Decision Making.

Knowledge Scores

Before the surgeon visit, 41% of patients had a ≥60% knowledge score. The rate did not vary by DA group or surgeon group (usual care vs. use of patient preference report). After the visit, 67% of the sample met the ≥60% criterion, and again, the rates were similar across DA and surgeon groups.

However, average knowledge scores were significantly higher with a short DA than with a long DA, both before the visit and one week afterward. For example, before the visit, for patients who said they reviewed their entire DA, the average knowledge score was 90% in the short DA group and 79% in the long DA group. A short DA was especially helpful for patients under 65.

Treatment Preferences and Treatments Received

Before the visit, more than one-third of patients had no clear treatment preference: 38% of those who used the short DA and 39% of those who used the long DA. After the visit, only 11% and 10%, respectively, said they felt unsure.

There was high concordance between the treatment preference that patients had one week after the visit and the treatment they eventually received:

• 74% of patients said at six months that they had received the treatment they preferred. There was no difference between DA groups, and the patient preference reports to surgeons had no measurable impact on this outcome
• 16% of patients preferred surgery but had not received it within six months of the visit. However, 50 of those 150 respondents said they had surgery scheduled
• 10% of patients did not have a clear preference at one week post-visit

Surgeon Satisfaction

Eight surgeons received surveys after a random 30% of their visits with enrolled patients. Most surgeons were extremely or very satisfied with the visits (85%) and reported that the visit duration was either normal (69%) or shorter than normal (20%). These findings were consistent across DA groups and whether or not the surgeon had received a patient preference report.

Takeaway Messages

Although short DAs outperformed long DAs with regard to knowledge scores, both types of DAs performed well. The fact that knowledge scores continued to be high after the visits suggest the information in the DAs was reinforced by the surgeons and retained by the patients.

The patient preference reports did not influence the rates of concordance between patient preference and actual treatment. 90% of the reports were delivered to the surgeons, but exit interviews with surgeons suggested the reports were not well-used during the visits. To ensure genuine shared decision-making about elective surgery, surgeons should take care to discuss with patients their goals and treatment preferences.

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