Decision aid for patients considering total knee arthroplasty with preference report for surgeons: a pilot randomized controlled trial

Dawn Stacey, Gillian Hawker, Geoffrey Dervin, Peter Tugwell, Laura Boland, Marie-Pascale Pomey, Annette M O'Connor, Monica Taljaard, Dawn Stacey, Gillian Hawker, Geoffrey Dervin, Peter Tugwell, Laura Boland, Marie-Pascale Pomey, Annette M O'Connor, Monica Taljaard

Abstract

Background: To evaluate feasibility and potential effectiveness of a patient decision aid (PtDA) for patients and a preference report for surgeons to reduce wait times and improve decision quality in patients with osteoarthritis considering total knee replacement.

Methods: A prospective two-arm pilot randomized controlled trial. Patients with osteoarthritis were eligible if they understood English and were referred for surgical consultation about an initial total knee arthroplasty at a Canadian orthopaedic joint assessment clinic. Patients were randomized to the PtDA intervention or usual education. The intervention was an osteoarthritis PtDA for patients and a one-page preference report summarizing patients' clinical and decisional data for their surgeon. The main feasibility outcomes were rates of recruitment and questionnaire completion; the preliminary effectiveness outcomes were wait times and decision quality.

Results: Of 180 patients eligible for surgical consultation, 142 (79%) were recruited and randomized to the PtDA intervention (n = 71) or usual education (n = 71). Data collection yielded a 93% questionnaire completion rate with less than 1% missing items. After one year, 13% of patients remained on the surgical wait list. The median time from referral to being off the wait list (censored using survival analysis techniques) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) and 33.0 weeks for usual education (n = 71, 95% CI: 26.1, 39.9). Patients exposed to the PtDA had higher decision quality based on knowledge (71% versus 47%; p < 0.0001) and quality decision being an informed choice that is consistent with their values for option outcomes (56.4% versus 25.0%; p < 0.001).

Conclusions: Recruitment of patients with osteoarthritis considering surgery and data collection were feasible. As some patients remained on the surgical waiting list after one year, follow-up should be extended to two years. Patients exposed to the PtDA achieved higher decision quality compared to those receiving usual education but there was no difference in wait for surgery.

Trials registration: ClinicalTrials.Gov NCT00743951.

Figures

Figure 1
Figure 1
Summary report for surgeons [26].
Figure 2
Figure 2
CONSORT trial flow diagram.
Figure 3
Figure 3
Wait times (screening to definitive decision) by group.

References

    1. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Twoheed T, Welch V, Wells G, Tugwell P. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64:465–474.
    1. Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275:858–865. doi: 10.1001/jama.1996.03530350040032.
    1. Liang MH, Larson M, Thompson M, Eaton H, McNamara E, Katz R, Taylor J. Costs and outcomes in rheumatoid arthritis. Arthritis Rheum. 1984;27:522–529. doi: 10.1002/art.1780270507.
    1. National Institutes of Health (NIH) NIH Consensus Development Conference Statement - Total Knee Replacement. 2003. .
    1. Snider MG, MacDonald SJ, Pototschnik R. Waiting times and patient perspectives for total hip and knee arthroplasty in rural and urban Ontario. Can J Surg. 2005;48:355–360.
    1. Wait time Alliance. Canadians still waiting too long for health care: Report card on wait times in Canada. 2013. .
    1. Ontario Ministry of Health and Long-Term Care. Ontario Wait Times. 2013. .
    1. Conner-Spady B, Estey A, Arnett G, McGurran J, Noseworthy T. Steering Committee of the Western Canada Waiting List Project. Prioritization of patients on waiting lists for hip and knee replacement: validation of a priority criteria tool. Int J Technol Assess Health Care. 2004;20:509–515.
    1. Conner-Spady B, Estey A, Arnett G, Ness K, McGurran J, Bear R, Noseworthy T. Steering Committee of the Western Canada Waiting List Project. Determinants of patient and surgeon perspectives on maximum acceptable waiting times for hip and knee arthroplasty. J Health Serv Res Policy. 2005;10:84–90. doi: 10.1258/1355819053559155.
    1. Meleskie J, Wilson K. Development of a regional clinical pathway for total hip replacement in a rural health network. Healthc Q Online Case Study . 2004. pp. 1–7. Available at: .
    1. Cipriano LE, Chesworth BM, Anderson CK, Zaric GS. Estimating the effect of total joint replacement wait time strategies in Ontario using simulation modeling. Boston, MA; 2006. (Presented at the Society for Medical Decision Making Annual Meeting).
    1. Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012;22(3):274–277. doi: 10.1097/JSM.0b013e318248ed24.
    1. Llewellyn-Thomas HA, Arshinoff R, Bell M, Williams JI, Naylor CD. the Ontario Hip and Knee Replacement Project Team. In the queue for total joint replacement: patients’ perspective on waiting times. J Eval Clin Pract. 1998;4:63–74. doi: 10.1046/j.1365-2753.1998.t01-1-00006.x.
    1. Weinstein JN, Bronner KK, Morgan TS, Wennberg JE. Trends and geographic variations in major surgery for degenerative diseases of the hip, knee, and spine. Health Aff. 2004;web exclusive:Var-81-Var-89.
    1. Hawker GA, Wright JG, Badley EM, Coyte PC. Perceptions of, and willingness to consider, total joint arthroplasty in a population-based cohort of individuals with disabling hip and knee arthritis. Arthritis Rheum. 2004;51:635–641. doi: 10.1002/art.20524.
    1. Williams J, Shipton D, Badley EM, Hawker G, Kreder H, DeBoer D, Guan J, Mohomed N. In: Arthritis and Related Conditions in Ontario: ICES Research Atlas. Badley EM, Glazier RH, editor. Toronto: Institute for Clinical Evaluative Sciences; 2004. Surgical services.
    1. Hawker GA. Who, when, and why total joint replacement surgery? The patient's perspective. Curr Opin Rheumatol. 2006;18:526–530.
    1. Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol. 2002;29:1273–1279.
    1. Suarez-Almazor ME, Souchek J, Kelly PA, O'Malley K, Byrne M, Richardson M, Pak C. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165:1117–1124. doi: 10.1001/archinte.165.10.1117.
    1. Marcinkowski K, Wong VG, Dignam D. Getting back to the future: a grounded theory study of the patient perspective of total knee joint arthroplasty. Orthop Nurs. 2005;24:202–209.
    1. Figaro MK, Williams-Russo P, Allegrante JP. Expectation and outlook: the impact of patient preference on arthritis care among African Americans. J Ambul Care Manage. 2005;28:41–48. doi: 10.1097/00004479-200501000-00006.
    1. Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JH. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014. pp. 1–335.
    1. Bozic KJ, Belkora J, Chan V, Youm J, Zhou T, Dupaix J, Bye AN, Braddock III CH, Chenok KE, Huddleston III JI. Shared decision making in patients with osteoarthritis of the hip and knee. J Bone Joint Surg. 2013;95:1633–1639. doi: 10.2106/JBJS.M.00004.
    1. de Achaval S, Fraenkel L, Volk RJ, Cox V, Suarez-Almazor ME. Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty. Arthritis Care Res. 2012;64:229–237. doi: 10.1002/acr.20646.
    1. Elwyn G, O'Connor A, Stacey D, Volk R, Edwards A, Coulter A, Thomson R, Barratt A, Barry M, Bernstein S, Butow P, Clarke A, Entwistle V, Feldman-Stewart D, Holmes-Rovner M, Llewellyn-Thomas H, Moumjid N, Mulley A, Ruland C, Sepucha K, Sykes A, Whelan T. International Patient Decision Aids Standards (IPDAS) Collaboration. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. Br Med J. 2006;333:417–422. doi: 10.1136/.
    1. Stacey D, Hawker G, Dervin G, Tomek I, Cochran N, Tugwell P, O’Connor A. Improving shared decision making in osteoarthritis. Br Med J. 2008;336:954–955. doi: 10.1136/bmj.39520.699190.94.
    1. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, Robson R, Thabane M, Giangregorio L, Goldsmith CH. A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol. 2010;10:1–10. doi: 10.1186/1471-2288-10-1.
    1. Sepucha KR, Stacey D, Clay CF, Change Y, Cosenza C, Dervin G, Dorrwachter J, Feibelmann S, Katz JN, Kearing SA, Malchua H, Taljaard M, Tomek I, Tugwell P, Levin CA. Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation. BMC Musculoskelet Disord. 2011;12:1–12.
    1. Ferron Parayre A, Labrecque M, Rousseau M, Turcotte S, Legare F. Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients. Med Decis Making. 2013. Online First June 17:1-9.
    1. Bennett C, Graham ID, Kristjansson E, Kearing SA, Clay KF, O'Connor AM. Validation of a preparation for decision making scale. Patient Educ Couns. 2010;78:130–133. doi: 10.1016/j.pec.2009.05.012.
    1. Sepucha KR, Fowler FJ, Mulley AG. Policy support for patient-centered care: the need for measurable improvements in decision quality. Health Aff. 2004;Suppl:VAR54–VAR62.
    1. Collins ED, Moore CP, Clay KF, Kearing SA, O'Connor AM, Llewellyn-Thomas HA, Barth RJ, Sepucha KR. Can women with early-stage breast cancer make an informed decision for mastectomy? J Clin Oncol. 2009;27:519–525.
    1. Bekker HL, Hewison J, Thornton JG. Understanding why decision aids work: linking process with outcome. Patient Educ Couns. 2003;50:323–329. doi: 10.1016/S0738-3991(03)00056-9.
    1. Brehaut JC, O'Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E, Feldman-Stewart D. Validation of a decision regret scale. Med Decis Making. 2003;23:281–292. doi: 10.1177/0272989X03256005.

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