➢ Shared decision making is a strategy for making medical decisions that relies on active participation of both patient and physician, which may be an attractive option for the orthopaedic community as patients increasingly desire to play a more active role in medical decision making.
➢ Shared decision making and decision aids have been effective in improving patient knowledge about medical procedures and in reducing decisional conflict and improving the accuracy of patients’ risk perceptions, allowing patients to make a decision that is more in accordance with their particular values and thus leading to improved patient outcomes and satisfaction after total joint arthroplasty.
➢ The practice of shared decision making in hip and knee arthritis populations can lead to the establishment of patient-centered utilization rates and cost reduction.
➢ The optimal design of shared decision making on clinical practice in diverse patient populations and varied environments is yet to be defined.
Total joint arthroplasty remains a highly successful procedure for patients with disabling osteoarthritis, as the procedure has been shown to result in decreased pain and improved function and quality of life1. Consequently, the demand for total joint arthroplasty continues to increase with the growing elderly population. Currently, the estimated annual need for hip and knee arthroplasty procedures in the United States is projected to grow to four million by the year 20302. However, despite the positive outcomes achieved with total joint arthroplasty, there is substantial regional variation in the incidence of total joint arthroplasty, which is not based on population differences alone and is difficult to explain3. Hip and knee osteoarthritis is a preference-sensitive condition, resulting in the introduction of subjectivity into its management, which may partially explain the variation observed4. There are no clear clinical guidelines for the indication of total joint arthroplasty, and it is common to find differences among surgeons regarding what is considered to be a specific indication for total joint arthroplasty5. In fact, the incidence of total joint arthroplasty with regard to the appropriateness of the indication is not known6. One proposed method of helping patients make a decision about total joint arthroplasty, and thereby reducing the variability in incidence of total joint arthroplasty, is to incorporate a formal process for informing patients, eliciting their preferences, and involving them in their choice of treatment7-10. This is the concept behind shared decision making.
Shared decision making is a strategy for making medical decisions that relies on the active participation of both the patient and the physician10. It has several potential benefits that make it attractive to the orthopaedic community. First, there have been substantial improvements in patient satisfaction with the decision for operative treatments when shared decision making is utilized in the preoperative period11. In addition, it may have a favorable impact on health-care economics by ensuring that utilization of procedures is driven by patients, who, when fully informed, often choose fewer interventions, rather than by doctors, who often favor more interventions. Both of these are important goals for total joint surgeons in an era of valued-based purchasing. In addition, patients have a right to fully understand their medical options and to make decisions based on their perception of the potential harms and benefits of a particular intervention. In this article, we will clearly define the term shared decision making and discuss the current role that shared decision making plays in clinical orthopaedic practice. We will also discuss the importance of shared decision making and the rationale for its utilization. Lastly, we will discuss some of the barriers to shared decision making in orthopaedic surgery.
Patient involvement in medical decision making continues to increase and evolve as we depart from the paternalistic decision-making model in which surgeons unilaterally make medical decisions for patients12. The paternalistic model assumes that the patient and the physician share the same goals, values, and preferences and that the physician knows what is best for the patient in all cases13. With this model, however, there is good evidence that patients frequently do not understand the decisions that they make14. In addition, physicians are sometimes not very good at predicting patient preferences, although this can vary, depending on the condition that is being treated15,16. The departure from the paternalistic model has been spurred on by the growing body of information available to patients, leading to the development of a variety of new models of decision making. One such model has been labeled the informed decision-making model. In informed decision making, the patient is the sole individual responsible for deliberating and making a treatment decision. In this model, the physician must communicate sufficient information on medical alternatives to allow the patient to make an informed decision. The decision is then assumed to be aligned with the patient’s values because the patient makes the decision independently of the physician17. The challenge with this model is that the decisions are often challenging and beyond the capacity and/or the comfort level of the patient. Despite the physician’s efforts in educating the patient, the required depth of understanding to make complex decisions may not be achieved, resulting in an unsuccessful or unsatisfactory decision-making process for the patient.
The shared decision-making model attempts to incorporate the best features of each of these models to create a process whereby the patient and the physician both actively contribute to the medical decision. The Informed Medical Decisions Foundation defines this shared decision-making process as “a collaborative process that allows patients and their providers to make health-care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”18 This model relies on the physician’s expert knowledge of risk, benefits, and medical alternatives, while not neglecting the patient’s values and preferences. This is done through the development of strong patient-physician relationships that allow the patient and physician to reach a consensus through a two-way exchange of information19.
Rationale for Shared Decision Making in the Arthritis Population
Patients increasingly desire to play a more active role in medical decision making. Several patient surveys have demonstrated that as much as 75% of patients believe that treatment decisions should be made by them and the doctor together20. A cross-sectional survey of adults older than sixty-five years demonstrated that more than 98% of participants agreed with the statement, “I prefer that my doctor offer me choices and ask my opinion.”21 This overwhelming drive for more patient involvement in medical decision making has led to a growing body of literature on shared decision making. In a recent Cochrane review of eighty-six randomized controlled trials, the use of tools, known as decision aids, that allow a patient to participate in the decision-making process consistently increased patient knowledge, improved patient-provider communication, increased active participation in decision making, reduced decisional conflict, and helped patients reach decisions that are aligned with their stated values11. The impact on clinical workflow was variable, sometimes resulting in shorter or longer office visits11. The positive patient response to shared decision making in the United States has led many states to pass or consider passing legislation to mandate shared decision-making approaches22. However, despite the preference-sensitive nature of total joint arthroplasty and the increasing attention paid to shared decision making in the medical literature, a relatively small percentage of studies have dealt directly with total joint arthroplasty.
Another rationale for the use of shared decision making is that participation in high-quality, fully informed decisions may simultaneously improve patient satisfaction and decrease litigation risks for the physician. Studies have shown that reasons for patient dissatisfaction after total knee arthroplasty include unrealistic patient expectations and uninformed perceptions of potential benefits associated with the procedure22. Shared decision making has demonstrated improved patient satisfaction when used in the setting of arthritis care and the treatment of other chronic diseases23,24. Patient dissatisfaction has been demonstrated to be an important reason for litigation after hip and knee arthroplasty25. A mock trial study demonstrated that the use of a decision aid offered increased malpractice protection, with 94% of jurors viewing consent as adequate when a decision aid was used, compared with 72% when only a chart note was present26. Washington State passed a statute in 2007 stating that if a physician uses a certified patient decision aid, there is a presumption that the provider has conducted the informed consent process, and this presumption can only be overcome by clear and convincing evidence that the provider has not obtained informed consent, which is a substantially higher burden of proof than that required in cases in which a certified decision aid was not used27. Consequently, an argument can be made that the use of decision aids may be effective in decreasing litigation and malpractice premiums after total joint arthroplasty by improving overall patient satisfaction and providing evidence that physicians have satisfied their legal obligation to fully inform patients28.
Another proposed benefit to the practice of shared decision making is that it redefines the concept of appropriate utilization in patient-centered terms. In shared decision making, the appropriate candidate for operative intervention is a person who has a condition that is amenable to operative treatment, who understands his or her treatment options, who weighs the risks and benefits, and who then chooses surgery because it aligns with his or her medical goals and values. The right rate of operation is the rate at which informed patients such as these choose it.
Decision aids appear to affect health-care utilization in different ways. Shared decision making does not appear to increase the costs to the health-care system and may help reduce them. Decision aids have been shown to help patients form or strengthen their treatment preferences for orthopaedic conditions in a balanced way that does not seem to sway them for or against operative intervention29. Among trials assessed in the Cochrane review, patients receiving decision aids were less likely to choose operative intervention11. In a randomized trial involving approximately 175,000 commercially insured health-plan members, Wennberg et al. found that people who participated in intensive education, outreach, and shared decision making required less medical care and fewer hospitalizations and were less likely to choose an operation (−9.8%) to treat preference-sensitive conditions, including hip and knee replacement30. A recently published randomized controlled trial by Arterburn et al. demonstrated that shared decision making was associated with a substantial decrease in the rate of elective hip and knee replacement over an eighteen-month period in their health system, despite an increase in surgery rates for patients who actually viewed a decision aid31. There was an associated reduction in the 180-day cost of care, in the range of 12% to 21%. This has led some to conclude that shared decision making can be cost saving and can be used to guide a population toward the appropriate level of care; however, the age of patients who received decision aids and elected to be treated with total joint arthroplasty was substantially higher than that of patients choosing operative intervention in the control group, which may have impacted the treatment strategy initially chosen by patients in the study. The researchers postulated that this indicated that the introduction of shared decision making may result in a decrease in younger, less severely affected patients who choose total joint replacement as the treatment for their arthritis. It remains to be established whether this is appropriate and what the control patients will choose in the future, and the appropriate utilization rate of joint replacement also remains to be clearly established.
Willingness of the Patient to Be Involved in Shared Decision Making
Multiple studies have demonstrated that patients, including elderly patients, increasingly want to play an active role in their medical decision making, although barriers and concerns about physician perceptions by patients wanting to be actively involved in clinical decision making persist32-34. Patients who are provided with the best available evidence about their illness and treatment options are more likely to actively participate in their care35. In addition, repeat exposure to decision aids has been shown to increase active participation by the elderly in self-care as well as with regard to healthy behaviors in low-income patients with limited health literacy36,37, although these studies did not specifically examine patients in arthroplasty subspecialty offices. In describing preferred roles in medical decision making, almost all participants (98%) of one study agreed with the statement “I prefer that my doctor offer me choices and ask my opinion.”21 This indicates that a substantial number of patients within the age range of most total joint arthroplasty patients would like to actively participate in their treatment decisions.
Willingness of the Orthopaedic Surgeon to Participate in Shared Decision Making
Momentum continues to grow in support of shared decision making among surgeons who do total joint arthroplasty. Seventy-nine percent of 362 responding joint replacement surgeons in the United Kingdom thought that patient decision aids were a “good” or “excellent” idea38. North American studies have demonstrated a similar trend39; however, only a small percentage (13%) of surgeons stated that they would use a decision aid during a surgical consultation. The most common barrier to use of a decision aid is a concern that it may add time and work to an already busy clinic schedule38. In addition, some surgeons are concerned that decision aids will be difficult to update and that patients may not want to use them38. A study of Canadian physicians demonstrated several concerns40. In this study, physicians voiced concern with the complexity of decision aids, the cost that they would produce, the appropriateness for some patient populations, and the time required to incorporate the aid into patient consultations. In a study of 141 informed decision-making discussions on various orthopaedic topics, including hip and knee arthroplasty, surgeons who had effective shared decision-making conversations did not have substantially longer office visits compared with their colleagues. The visit times in the study ranged from ten to twenty-one minutes, with an average of sixteen minutes41. While questions remain, this study demonstrates that shared decision-making practices can be successfully introduced into the clinical setting without a detrimental effect on the clinical work flow or office-visit times. Despite the concerns that have been raised regarding shared decision making, the American Association of Hip and Knee Surgeons as well as the American Academy of Orthopaedic Surgeons has demonstrated a positive sentiment toward shared decision making and it is likely to remain an important part of the discussion regarding arthritis treatment going forward9.
Decision aids are tools for providing accurate information to patients in successful shared decision-making models for the purpose of allowing a patient to participate in the decision-making process. They provide evidence-based information, including estimates of risks and benefits and available medical alternatives13. There are a variety of formats for decision aids, including linear written documents, pamphlets, videos, interactive multimedia programs, and counseling tools42,43. They often include treatment strategies and outcomes, patient testimonials, and tools that help patients clarify personal preferences42,44. These aids are meant to supplement the counseling of patients by physicians—but they cannot and should not replace it—and they are not simply patient education materials. Decision aids include tools to establish goals and expectations; they are distinguished from simple education materials in that they examine preferences and how they relate to a patient’s goals and ability to cope with a condition (such as hip or knee arthritis) through various treatment strategies45-48. They provide evidence-based information, including estimates of risks, benefits, and available medical alternatives. Decision aids can be self-administered or clinician-administered and should be used as an adjunct to the doctor-patient encounter and not as a substitute for face-to-face counseling. After a patient has used the decision aid, it is necessary to assess the patient’s knowledge about the available options as well as the patient’s values and opinions regarding the risks and benefits49. Any unresolved issues should be clarified so that the patient can make an informed decision48. In a review of ninety-eight decision aids by Feldman-Stewart et al., the completeness, balance, and accuracy was called into question50. The authors found that few aids sought patient input, that only 43% of aids described the natural history, and that only 54% of aids described the procedure for each available option. Consequently, the International Patient Decision Aids Standards (IPDAS) Collaboration was formed51, and the IPDAS Collaboration has created a checklist of the essential elements of an adequate patient decision aid52.
A Cochrane Collaboration systematic review evaluated the effect of decision aids across a number of clinical decisions. This review demonstrated that decision aids improve patient understanding, improve patient perception of risks and benefits, reduce decisional conflict, lead to fewer patients remaining undecided, and result in greater concordance between patient values and the chosen treatment option19. While this review did not include any studies involving total joint arthroplasty, several studies have examined the effectiveness of decision aids in the total joint arthroplasty patient population. Currently, decision aids have been used in multiple formats, including booklets or pamphlets, audio tapes, compact discs (CDs), audiovisual digital optical disc storage formats (DVDs), and interactive web sites. Booklets, the Internet, and computer-based aids and pamphlets have all been demonstrated to be a successful medium in randomized controlled trials in total joint arthroplasty clinics24,43. In a survey of total joint replacement surgeons, more than half of responding surgeons stated that they preferred a take-home pamphlet alone39. In contrast, the results of a large study by Spunt et al. demonstrated that a video disc was an effective decision aid in patients with back pain53.
Videos have also been used as effective decision aids in the treatment of osteoarthritis of the knee. In a study by Weng et al., 102 veterans of black or white race were given an educational video on total knee arthroplasty. The patient’s response to the video was assessed on how informative it was, its understandability, and its usefulness in decision making54. Both groups endorsed the video and thought that it was useful in the decision-making process. The study went on to demonstrate an improvement in expectations for blacks, with only a small change from baseline for whites, suggesting a possible mechanism for combating ethnic decisional disparities. In a three-arm randomized trial by de Achaval et al. investigating the effect of different decision aids in patients with knee osteoarthritis, reduction in decisional conflict was substantially greater when patients were exposed to an audiobooklet (i.e., a video plus a booklet) than when they received a more complex intervention that combined the audiobooklet with a computer-based program that required patients to evaluate trade-offs by ranking competing risks and benefits. Both of these decision aids were more effective than a simple control intervention consisting of an informational pamphlet alone55. A survey of more than 200 arthroplasty surgeons in the United Kingdom revealed that a majority of surgeons favored using a booklet format39. Consequently, it is evident that there is no consensus on the ideal method of utilizing decision aids with regard to total joint arthroplasty. Further research regarding the ideal format is needed, and this is likely to vary depending on the local care environment in which a physician practices.
As the free exchange of knowledge increases, particularly via web-based media, there is an increasing portion of the patient population that demands active involvement in medical decision making31. Shared decision making is a clinical tool that allows patients to be involved in the decision-making process through improved patient knowledge and decision-making ability19. Shared decision making has been incorporated successfully into many medical decisions, including orthopaedic surgery. There are several arguments for increasing the practice of shared decision making. It has been an effective method for improving patient knowledge about medical procedures and reducing decisional conflict, allowing patients to make decisions more in accordance with their particular values19. This may lead to increased patient participation in their care and improved patient outcomes and satisfaction after total joint arthroplasty, which would justify expansion of the practice of shared decision making24,36,37.
The optimal design and impact of shared decision making on clinical practice remain poorly defined. It has been demonstrated that decision aids for use in shared decision making can be introduced into standard clinical work flow in some settings, with minimal disruption41. As a result, some states and policymakers are considering legislation that would provide funding for shared decision making, and Washington State has pending legislation that would fund shared decision making56. In addition, the Patient Protection and Affordable Care Act includes several projects that may include additional reimbursement for physicians who incorporate shared decision-making programs in their clinical practice57.
Another potential benefit of shared decision making in hip and knee arthritis populations is the establishment of patient-centered utilization rates and cost reduction. The recent randomized controlled trial by Arterburn et al. demonstrated a reduction in total health-care costs after the initiation of shared decision-making programs in hip and knee osteoarthritis31. The majority of these savings resulted from an overall decrease in total joint arthroplasty and the increase in patients electing to proceed with nonoperative management in the shared decision-making group. The long-term importance of this finding remains to be elucidated. The introduction of shared decision making could lead to a simple delay in total joint replacement and an overall long-term increase in use of services. In addition, if patients wait until function substantially deteriorates before undergoing total joint replacement, the outcome of the procedure could be compromised. Furthermore, surgeons interested in improving decision quality and patient satisfaction may be hesitant to practice shared decision making if they believe that it will have a negative impact on a patient’s likelihood to opt for operative treatment in a fee-for-service environment. Therefore, the potential for shared decision making to be a tool for containing health-care costs and establishing appropriate total joint arthroplasty utilization rates remains to be established and requires further exploration.
The management of hip and knee arthritis involves preference-sensitive decisions that lend themselves to shared decision making. However, several issues remain to be clarified. The optimal program design and decision-aid format remain unclear. The ideal manner in which to incorporate shared decision making into varied clinical environments with diverse patient populations, and the long-term impact on arthroplasty utilization, need further clarification.
Source of Funding: No source of funding was used for this manuscript.
Investigation performed at the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, and the Foundation for Informed Decision Making, Boston, Massachusetts
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated