Pilot Study Examining Feasibility and Comparing the Effectiveness of Decision Aids for Hip and Knee Osteoarthritis: A Randomized Trial

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

A Nomogram for Predicting Non-Response to Surgery One Year after Elective Total Hip Replacement

Background: Total hip replacement (THR) is a common and cost-effective procedure for end-stage osteoarthritis, but inappropriate utilization may be devaluing its true impact. The purpose of this study was to develop and test the internal validity of a prognostic algorithm for predicting the probability of non-response to THR surgery at 1 year. Methods: Analysis of outcome data extracted from an institutional registry of individuals (N = 2177) following elective THR performed between January 2012 and December 2019. OMERACT-OARSI responder criteria were applied to Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain and function scores at pre- and 1 year post-THR, to determine non-response to surgery. Independent prognostic correlates of post-operative non-response observed in adjusted modelling were then used to develop a nomogram. Results: A total of 194 (8.9%) cases were deemed non-responders to THR. The degree of contribution (OR, 95% CI) of each explanatory factor to non-response on the nomogram was, morbid obesity (1.88, 1.16, 3.05), Kellgren−Lawrence grade <4 (1.89, 1.39, 2.56), WOMAC Global rating per 10 units (0.86, 0.79, 0.94) and the following co-morbidities: cerebrovascular disease (2.39, 1.33, 4.30), chronic pulmonary disease (1.64; 1.00, 2.71), connective tissue disease (1.99, 1.17, 3.39), diabetes (1.86, 1.26, 2.75) and liver disease (2.28, 0.99, 5.27). The concordance index for the nomogram was 0.70. Conclusion: We have developed a prognostic nomogram to calculate the probability of non-response to THR surgery. In doing so, we determined that both the probability of and predictive prognostic factors for non-response to THR differed from a previously developed nomogram for total knee replacement (TKR), confirming the benefit of designing decision support tools that are both condition and surgery site specific. Future external validation of the nomogram is required to confirm its generalisability.

Patient Engagement Approaches in Total Joint Arthroplasty: A Review of Two Decades

Patient engagement is a comprehensive approach to health care where the physician inspires confidence in the patient to be involved in their own care. Most research studies of patient engagement in total joint arthroplasty (TJA) have come in the past 5 years (2015-2020), with no reviews investigating the different patient engagement methods in TJA. The primary purpose of this review is to examine patient engagement methods in TJA. The search identified 31 studies aimed at patient engagement methods in TJA. Based on our review, the conclusions therein strongly suggest that patient engagement methods in TJA demonstrate benefits throughout care delivery through tools focused on promoting involvement in decision making and accessible care delivery (eg, virtual rehabilitation, remote monitoring). Future work should understand the influence of social determinants on patient involvement in care, and overall cost (or savings) of engagement methods to patients and society.

Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review

OBJECTIVE

To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain.

METHODS

We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting.

RESULTS

Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format.

CONCLUSIONS

Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.