Do patient decision aids reduce wait times and improve quality of

decisions for patients considering TJA?

A randomized controlled trial

University of Ottawa, Ottawa Hospital Research Institute; University of Toronto and Women’s College Hospital; Dartmouth College, New Hampshire; University of MontrealOctober 2014

D Stacey, G Dervin, M Taljaard, I Tomek, P Tugwell, A O’Connor, G Hawker

Funding: Informed Medical Decisions Foundation

Outline

• Standardized screening process

• Evaluation of first year of patients screened

• Effectiveness of patient decision aid

• The Ottawa Hospital Orthopedic Intake Clinic– Launched in December 2006– staffed by 1 of 4 MSK physicians

TOH Joint Screening Clinic

.

.

Conner-Spady B, Estey A, Arnett G, Ness K, McGurran J, Bear R et al. 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(4):509-515

NIH criteria for knee replacement

1. Radiographic evidence of joint damage2. Moderate to severe persistent pain that is not

adequately relieved by an extended course of non-surgical management

3. Clinically significant functional limitation resulting in diminished quality of life

NIH Consensus Development Conference Statement - Total Knee Replacement. http://consensus.nih.gov/2003/2003TotalKneeReplacement117html 2003.

Outline

• Standardized screening process

• Evaluation of first year of patients screened

• Effectiveness of patient decision aid

* Other: walking aid (33), acupuncture (2), exercise (2), massage (1), wheelchair (1), physiatrist(1)

ResultsApr 07 – Mar 08

47.4% referred back to family physician

52.6% surgeon consult

327 patients screened

81.4% surgery

18.6% no surgery- other health issues (7) - patient decision (6)- symptoms resolved (6)

Referred to Surgeon

(N=172)

Not Referred to Surgeon

(N=155)P value

Age (mean; SD) 67 (10.6) 63 (11.2) N/S

Percent female 65.7% 62.6% N/S

BMI (mean; SD) 33.3 (6.5) 33.3 (7.4) N/S

Medication tried 93.0% 91.0% N/S

Injections tried 58.7% 32.3% <0.001

Physiotherapy tried 33.1% 36.8% N/S

Tried 3 or more measures 18.6% 11.0% 0.01

Met 3 NIH criteria 86.5% 33.3% <0.001

WOMAC (96 points) (mean; SD)

56.2 (17.)8 46.5 (21.5) <0.001

HKPT (80 points)(mean; SD)

44.8 (15.6) 23.9 (14.1) <0.001

Results

Summary

• Underuse of conservative measures prior to referral

• Use of sport med physicians and screening tools resulted in ~50% reduction in surgical consultations

• Most patients referred on to surgeon received surgery

• Patients with milder OA need management in the community

Outline

• Standardized screening process

• Evaluation of first year of patients screened

• Effectiveness of patient decision aid

Usual care/education• Hospital booklet on

joint replacement • Summary report of

clinical priority sent to surgeon

Participants were randomized to

+ Patient Decision Aid• Patient decision aid: DVD

and booklet from Health Dialog

• Patient decision guide (knowledge, clarity of values, preference)

• Summary report of patient preference (and

clinical priority) sent to surgeon

®

16Stacey, D. et al. BMJ 2008;0:bmj.39520.701748.94v2-bmj.39520.701748.94

Copyright ©2008 BMJ Publishing Group Ltd.

BMI=27

 Participant characteristics

Decision Aid(n=167)

Usual Care(n=167)

Hip (n) 47 45 Knee (n) 120 122Age (mean years) 66.1 66.9 Men (n) 78 64 Women (n) 89 103 Education: Less than high school(n)  11  13

High/trade/technical school (n) 76 70College (n) 32 24

University/graduate degree (n) 48 60 Living arrangements: live alone (n) 39  44 

live with someone else (n) 128 123 Employment full time(n) 31  33 

part time (n) 12 18retired (n) 105 106other (n) 11 18Income/ <20,000 to <20,000 to

Year >100,000 >100,000

Wait times: PtDA 118 days (95% CI: 109 to 140)Usual 144 days (95% CI: 121 to 164)

Achieving decision quality(knowledge score >66%; values predicting actual choice +50%)

Yes, 45%Yes, 56%

0.0%

25.0%

50.0%

75.0%

100.0%

Usual CareDecision Aid

% p

atie

nts

ach

ievi

ng

dec

isio

n q

ual

ity

RR 1.25 (95% CI 1.0 to 1.6)

Actual decision

Had surgery

NoSurgery

Loopback

surgery

Patient Decision Aid(n=164)

73.2% 19.5% 7.3%

Usual Care(n=164)

80.5% 14.6% 4.9%Surgery: Mantel Haenszel 0.91 (95% CI 0.8-1.0)

Loopback: Mantel Haenszel 1.11 (95% CI 0.5-2.5)

Process of decision makingItems Patient

decision aidUsual care

P-values

Knowledge (out of 100) 68.9% 61.1% <0.001

Feel informed 93.6% 79.6% <0.001

Feel clear about values 88.5% 79.6% 0.046

Feel supported in making choice 85.3% 80.3% No diff

Feel sure about best choice 70.5% 76.4% No diff

Know decision depends on values 5 of 5 4 of 5 0.003

Help prepare to talk to doctor 5 of 5 4 of 5 0.014

Help recognize a decision needs to be made

4 of 5 4 of 5 No diff

Help think about how involved they want to be

5 of 5 5 of 5 No diff

4-items SURE test (Decisional Conflict)4-items Preparation for Decision Making Scale

Summary of Findings

• Appears to be shorter wait in the patient decision aid group plus preference report for their surgeon (compared to usual care)

• Patient decision aid group had higher decision quality, felt more informed, clear about what matters most, prepared to discuss their values for outcomes of options with the surgeon, and knew that the decision depended on what mattered most to them.

• Overall, patient decision aids improved the process of decision making and resulted in higher decision quality

http://decisionaid.ohri.ca