Shared Decision Making in Patients With Osteoarthritis of the Hip and Knee

Status:	Completed
Conditions:	Arthritis, Arthritis, Osteoarthritis (OA)
Therapuetic Areas:	Rheumatology
Healthy:	No
Age Range:	Any
Updated:	11/18/2012
Start Date:	July 2011
End Date:	July 2014
Contact:	Kevin J Bozic, MD, MBA
Email:	bozick@orthosurg.ucsf.edu

Total joint arthroplasty (TJA) is an effective procedure for reducing pain and improving
function in patients with disabling osteoarthritis (OA) of the hip or knee. However, as with
all invasive procedures, TJA is associated with certain risks and substantial costs. Since
the indications for TJA are heavily dependent on patients' quality of life and expectations.
TJA utilization rates vary widely throughout the United States, as seen with other
'preference-sensitive' procedures. Early evidence suggests shared decision making (SDM)
strategies are effective in enhancing patient decision quality, or the degree to which
treatment decisions reflect the preferences of fully informed patients, especially for
preference-sensitive procedures like TJA. Despite these advantages, however, SDM has not
been embraced or widely adopted in orthopaedics. To investigate this limited uptake, the
investigators propose a series of evaluations of individual-level strategies. The
investigators innovative and unique contribution is to approach patients, surgeons and
healthcare purchasers as having symmetric and equally valid concerns about the benefits and
cost associated with SDM. The investigators overall objective is to facilitate wider
dissemination of SDM strategies in orthopaedic practices. The specific aims of the project
are to assess, for SDM strategies, the impact on key patient, surgeon, and healthcare
purchaser priorities; By achieving this aim our project will produce new interventions and
incentives for disseminating SDM that are endorsed as feasible and acceptable by a coalition
of patients, surgeons, and purchasers. The investigators plans for evaluation include a
randomized controlled trial to evaluate the impact of SDM on outcomes of interest to
patients, surgeons, and purchasers.

We propose an RCT based on a non-randomized pilot study conducted at UCSF that included 115
patients who were referred for evaluation of hip and knee OA. The results of this pilot
study suggested that DESI's were associated with greater patient knowledge, higher decision
quality, higher patient and surgeon satisfaction, and no substantial impact on length of
office visit or treatment decision. As in the pilot study, the RCT intervention will include
a package of decision and communication aids shown in prior studies to increase patient
knowledge, question-asking, and information recall. The intervention includes digital video
discs and booklets produced by the Foundation for Informed Medical Decision Making and
Health Dialog; a question-prompting phone call with a trained health coach; audio-recordings
of the patient-surgeon consultation; and a copy of the surgeon's dictated note. The control
arm will consist of usual care. Our primary outcome is the proportion of patients who arrive
at an informed decision during the first visit. This outcome is of interest to patients,
surgeons and healthcare purchasers, all of whom value efficiency and quality in delivery of
care. Our hypothesis is that a higher proportion of patients in the intervention group will
arrive at an informed decision during the first visit, as a result of being more
knowledgeable and prepared for their visit, thus conserving resources while advancing
quality. Secondary outcomes of interest will include treatment decision (e.g., surgical vs.
non-surgical); patient and provider satisfaction; length of office visits; and adherence to
treatment recommendations.

We will assess whether patients are informed or not using a survey instrument testing 19
consensus "key facts" developed by FIMDM based on evidence and expert opinion. We will
measure whether patients arrive at a decision using the Stage of Decision Making instrument.
We will administer both instruments immediately after the patient's first consultation with
their surgeon.

Inclusion Criteria:

- Chronic unilateral or bilateral osteoarthritis of the hip or knee

- At least 18 years of age

- Must be psychosocially, mentally, and physically able to fully complete the
questionnaires

- No previous joint replacement surgery

- First time visit to surgeon

Exclusion Criteria:

- Prior history of joint replacement surgery, ipsilateral or contralateral hip/knee
replacement

- Subjects whose primary diagnosis is not osteoarthritis

- Subjects who cannot speak or read English

- Subjects who are cognitively impaired

- Subjects who refuse to complete surveys

We found this trial at

sites

Stanford University

450 Serra Mall
Stanford, California 94305

(650) 723-2300