Profiles in Medical Excellence
Patients Making Informed Decisions About Their Care
After Group Health introduced a straightforward video laying out the pros and cons of joint replacements for patients with knee and hip arthritis, such patients chose such surgeries at sharply lower rates, according to study just published in the journal Health Affairs.
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After widespread implementation of the videos, known as “decision aids,” the rate of knee replacements plunged 38 percent, while hip replacements dropped 26 percent. The cost of caring for those patients also declined by 12 and 21 percent respectively over six months, according the study in the September issue of the journal.
“Decision aids are balanced sources of information that clearly present the evidence-based pros and cons of treatment options for a health condition,” said study leader David E. Arterburn, MD, MPH, a general internist and associate investigator at the Group Health Research Institute. Group Health has distributed more decision aids than any other single health care organization in the world.
People often have wishful thinking about what joint replacement can do for them, like a patient who thought he’d be his club’s singles-tennis champ again, said co-author Charles F. Jung, MD, Group Health’s chief of orthopedics. Biased information sources, including direct-to-consumer ads for artificial joints, may fuel such unrealistic expectations.
By contrast, the decision aid served as a reality check, describing factors including the three-month recovery time, the 10- to 20-year lifespan of artificial joints, and risks such as infection and possible reoperation. After people saw decision aids, they tended to come into a doctor’s office with more realistic expectations and have a more focused discussion about what matters most to them as individuals.
Dr. Arterburn and colleagues studied 9,515 patients with knee or hip arthritis who watched the decision aids and their subsequent choices about joint replacement surgery. It’s the first study to investigate how the use of these decision aids in routine clinical practice can affect care and costs, and it is the first major study of their use in knee and hip arthritis.
“Treatment decisions for some health conditions are highly sensitive to the preferences of patients and doctors,” said Dr. Arterburn, who also is an affiliate professor at the University of Washington in Seattle. “When patients have access to objective, easy-to-understand, evidenced-based information about the risks and benefits of a given treatment, they’re more likely to make informed choices that align with their preferences. In our experience, implementing decision aids often means less elective surgery and can also mean lower costs.”
The study’s findings are consistent with results of prior randomized trials of other kinds of decision aids. Those trials found that people who had access to decision aids tended to choose more conservative, less invasive options.
The study has big implications, because of the vast numbers of joint replacements performed annually. More than 27 million Americans suffer from arthritis, which can cause severe pain and restrict functioning, including employment. Joint replacement is among the most common U.S. orthopedic procedures, with more than 650,000 knees and 250,000 hips replaced each year, at a combined cost of $15.6 billion.
Previous studies have found many types of medical and surgical care too often vary widely by geographical area, depending mostly on the preferences of local medical providers. Decision aids are meant to decrease these “unwarranted variations in care” by informing patients about the risks and benefits of treatment options. The aids may also help patients to clarify what they want and need, so their values and preferences carry more weight in the decision-making process.
It’s important to remember that patients in pain do have alternatives to joint replacements. Surgery can reduce pain and improve function for many, but so can other, nonsurgical options. Because excess weight strains joints (particularly knees), the most important action is to lose any extra weight. Other options are physical therapy, nonsteroidal anti-inflammatory drugs like ibuprofen, avoiding injury, and a mix of low-impact exercise, like walking, swimming, and biking. These activities are also suggested for patients who choose surgery, to lower the risk of their new joint failing and needing to be replaced again, which can be more complicated.
In 2007, Washington became the first state to pass legislation recognizing the use of patient decision aids and “shared decision making” as a higher standard of informed consent. In shared decision making, health care providers inform patients about their options—often using decision aids—and help them to clarify what matters most to them and to make an informed decision.
For more on this study go to the Group Health Research Institute
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This work strengthens our ability to recruit the best clinicians to work as Group Health Physicians. “As a doctor, teaching the next generation of providers is professionally satisfying and fun,” adds Kauff. “It reminds you of everything you know, what you don’t know, and reaffirms why we chose this profession.”
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