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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
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Outline
• Standardized screening process
• Evaluation of first year of patients screened
• Effectiveness of patient decision aid
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• The Ottawa Hospital Orthopedic Intake Clinic– Launched in December 2006– staffed by 1 of 4 MSK physicians
TOH Joint Screening Clinic
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.
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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
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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.
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Outline
• Standardized screening process
• Evaluation of first year of patients screened
• Effectiveness of patient decision aid
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* Other: walking aid (33), acupuncture (2), exercise (2), massage (1), wheelchair (1), physiatrist(1)
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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)
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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
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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
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Outline
• Standardized screening process
• Evaluation of first year of patients screened
• Effectiveness of patient decision aid
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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
®
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16Stacey, D. et al. BMJ 2008;0:bmj.39520.701748.94v2-bmj.39520.701748.94
Copyright ©2008 BMJ Publishing Group Ltd.
BMI=27
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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
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Wait times: PtDA 118 days (95% CI: 109 to 140)Usual 144 days (95% CI: 121 to 164)
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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)
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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)
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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
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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
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http://decisionaid.ohri.ca