Encounter Decision Aid vs. Clinical Decision Support or Usual Care to Support Patient-Centered Treatment Decisions in Osteoporosis: The Osteoporosis Choice Randomized Trial II
Annie LeBlanc, Amy T Wang, Kirk Wyatt, Megan E Branda, Nilay D Shah, Holly Van Houten, Laurie Pencille, Robert Wermers, Victor M Montori, Annie LeBlanc, Amy T Wang, Kirk Wyatt, Megan E Branda, Nilay D Shah, Holly Van Houten, Laurie Pencille, Robert Wermers, Victor M Montori
Abstract
Purpose: Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.
Methods: Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.
Results: We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.
Conclusion: Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.
Trial registration: clinical trials.gov NCT00949611.
Conflict of interest statement
Competing Interests: The authors have declared that no competing interests exist.
Figures
References
- Crandall CJ, Newberry SJ, Diamant A, Lim YW, Gellad WF, Suttorp MJ, et al. (2012). Treatment To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report. Rockville (MD).
- National Osteoporosis Foundation (2013) Clinician's guide to prevention and treatment of osteoporosis Washington, DC: National Osteoporosis Foundation.
- Cramer JA, Gold DT, Silverman SL, Lewiecki EM (2007) A systematic review of persistence and compliance with bisphosphonates for osteoporosis. Osteoporos Int doi:101007/s00198-006-0322-8 18: 1023–1031.
- Seeman E, Compston J, Adachi J, Brandi ML, Cooper C, Dawson-Hughes B, et al. (2007) Non-compliance: the Achilles' heel of anti-fracture efficacy. Osteoporos Int doi:101007/s00198-006-0294-8 18: 711–719.
- Montori VM, Shah ND, Pencille LJ, Branda ME, Van Houten HK, Swiglo BA, et al. (2011) Use of a decision aid to improve treatment decisions in osteoporosis: the osteoporosis choice randomized trial. Am J Med 124: 549–556. 10.1016/j.amjmed.2011.01.013
- Scoville EA, Ponce de Leon Lovaton P, Shah ND, Pencille LJ, Montori VM (2011) Why do women reject bisphosphonates for osteoporosis? A videographic study. PLoS ONE 6: e18468 10.1371/journal.pone.0018468
- McCloskey E, Kanis JA (2012) FRAX updates 2012. Curr Opin Rheumatol 24: 554–560. 10.1097/BOR.0b013e328356d2f5
- Kanis JA, World Health Organization Scientific G (2007) Assessment of Osteoporosis at the Primary Health Care Level. Technical Report.
- Pencille LJ, Campbell ME, Van Houten HK, Shah ND, Mullan RJ, Swiglo BA, et al. (2009) Protocol for the Osteoporosis Choice trial. A pilot randomized trial of a decision aid in primary care practice. Trials 10: 113 10.1186/1745-6215-10-113
- Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Welch V, et al. (2008) Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane database of systematic reviews: CD001155.
- O'Connor AM (1995) Validation of a decisional conflict scale. Med Decis Making 15: 25–30.
- Hess LM, Raebel MA, Conner DA, Malone DC (2006) Measurement of adherence in pharmacy administrative databases: a proposal for standard definitions and preferred measures. The Ann Pharmacother 40: 1280–1288.
- Karve S, Cleves MA, Helm M, Hudson TJ, West DS, Hudson TJ, et al. (2008) An empirical basis for standardizing adherence measures derived from administrative claims data among diabetic patients. Med Care 46: 1125–1133. 10.1097/MLR.0b013e31817924d2
- Elwyn G, Edwards A, Wensing M, Hood K, Atwell C, Grol R. (2003) Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care 12: 93–99.
- Rabin R, de Charro F (2001) EQ-5D: a measure of health status from the EuroQol Group. Ann Medi 33: 337–343.
- Montori VM, Guyatt GH (2001) Intention-to-treat principle. CMAJ 165: 1339–1341.
- Cranney A, O'Connor AM, Jacobsen MJ, Tugwell P, Adachi JD, et al. (2002) Development and pilot testing of a decision aid for postmenopausal women with osteoporosis. Patient Educ Couns doi:101016/S0738-3991(01)00218-X 47: 245–255.
- Mullan RJ, Montori VM, Shah ND, Christianson TJ, Bryant SC, Gordon H, et al. (2009) The diabetes mellitus medication choice decision aid: a randomized trial. Arch Intern Med 169: 1560–1568. 10.1001/archinternmed.2009.293
- Wyatt KD, Branda ME, Anderson RT, Pencille LJ, Montori VM, et al. (2014) Peering into the black box: a meta-analysis of how clinicians use decision aids during clinical encounters. Implementation science 9: 26 10.1186/1748-5908-9-26
Source: PubMed