<p>Decision Aid Implementation and Patients’ Preferences for Hip and Knee Osteoarthritis Treatment: Insights from the High Value Healthcare Collaborative</p>

Abstract

Background: Shared decision making (SDM) research has emphasized the role of decision aids (DAs) for helping patients make treatment decisions reflective of their preferences, yet there have been few collaborative multi-institutional efforts to integrate DAs in orthopedic consultations and primary care encounters. Objective: In the context of routine DA implementation for SDM, we investigate which patient-level characteristics are associated with patient preferences for surgery versus medical management before and after exposure to DAs. We explored whether DA implementation in primary care encounters was associated with greater shifts in patients' treatment preferences after exposure to DAs compared to DA implementation in orthopedic consultations. Design: Retrospective cohort study. Setting: 10 High Value Healthcare Collaborative (HVHC) health systems. Study participants: A total of 495 hip and 1343 adult knee osteoarthritis patients who were exposed to DAs within HVHC systems between July 2012 to June 2015. Results: Nearly 20% of knee patients and 17% of hip patients remained uncertain about their treatment preferences after viewing DAs. Older patients and patients with high pain levels had an increased preference for surgery. Older patients receiving DAs from three HVHC systems that transitioned DA implementation from orthopedics into primary care had lower odds of preferring surgery after DA exposure compared to older patients in seven HVHC systems that only implemented DAs for orthopedic consultations. Conclusion: Patients' treatment preferences were largely stable over time, highlighting that DAs for SDM largely do not necessarily shift preferences. DAs and SDM processes should be targeted at older adults and patients reporting high pain levels. Initiating treatment conversations in primary versus specialty care settings may also have important implications for engagement of patients in SDM via DAs.

Shared Decision-making Lowers Medical Expenditures and the Effect Is Amplified in Racially-Ethnically Concordant Relationships

“…As important as SDM is to improving patient engagement and potentially costs of care, implementing and improving SDM in routine practice is challenging. [38][39][40] Some clinicianfacing interventions have been found to improve SDM, including peer-to-peer group learning and interprofessional orientation. 41 Improved evaluation approaches, evidence-based standards, and appropriate incentives are needed.…”

US practice adoption of patient-engagement strategies and spending for adults with diabetes and cardiovascular disease

“… 53 As a result, decision-aid use can sometimes be associated with the utilization of high-cost services. 18 , 54 High adoption practices all use motivational interviewing support for behavior change, which can require substantial non-clinician staff resources to monitor goals and follow-up on treatment decisions. 55 SDM and motivational interviewing may also shift older Medicare FFS patients with diabetes and/or CVD to use supportive and community-based services, including home health and long-term care, which can improve their quality of life.…”

“… 17 Decision aids are evidence-driven tools often used in the SDM process that present the likelihood of potential outcomes for each option, and value clarification exercises to elucidate patients’ goals. 18 …”

“…Adults with diabetes and/or CVD are high-priority populations for physician practices and health systems using SDM to provide objective information on benefits/harms to help patients clarify their values and make preference-aligned decisions. 18 Motivational interviewing involves patient-centered prioritization techniques to support patients with goal-setting for behavior change, including managing cardiovascular risk factors such as smoking cessation, diet, and physical activity. 19 , 20 SMAs are medical encounters where clinicians simultaneously meet with multiple patients, reinforcing self-management education and medication management as patients learn from the experiences and treatment of their peers.…”

Association between received treatment elements and satisfaction with care for patients with knee osteoarthritis seen in general practice in Denmark

“…Among several reasons for the lack of implementation of first-line treatments for knee OA [15][16][17][18][19] is a patient preference for adjunctive treatment elements [20]. General practitioners (GPs) worry that encouraging lifestyle changes may negatively affect the doctor-patient relationship [16,21,22].…”