Shared Decision Making for Hip andKnee Replacement Candidates
SEPTEMBER 6, 2012
Posted 9/05/12 on the Disease
Management Care Blog
Osteoarthritis
(a.k.a “degenerative arthritis) of the hip and knee just… sucks. Characterized
by activity-related pain in the affected joint, many otherwise physically fit
persons have to resort to pills, injections and, finally, an appointment with
an orthopedic surgeon to talk about joint replacement surgery.
What is less
appreciated is that osteoarthritis can have a waxing and waning course with
periods of relative remissions. What’s more, conservative treatment options can
lessen or delay the need for surgery. Last but not least, the surgery itself
involves months of recovery and the possibility of a nasty complication.
The
primary care physician Disease Management Care Blog presided over this
many times with its arthritis patients. It was generally reluctant to refer a
patient to an orthopedic surgeon because it knew that the patients would be
more interested in the potential benefits and pay less attention to the
downsides of surgery.
Enter shared
decision making (SDM). Defined as care that is respectful of and responsive to
individual patient preferences, needs, and values and ensures that patient
values guide all clinical decisions, the premise is that by giving patients the
information they need, they’ll be able to ultimately determine the course of
their care. That would include patients with severe hip or knee osteoarthritis
who are thinking about surgery but who also need to consider the option of
conservative management.
That’s why
this just-published Health Affairs study is noteworthy. All the 27 orthopedic
surgeons in the 5 Group Health Cooperative clinics introduced shared decision
making (SDM) for patients who were being evaluated with knee or hip
osteoarthritis. The intervention consisted of DVDs and booklets (from this
company) that were ordered by the surgeon prior to an appointment. The
materials could also be viewed on Group Health’s website at any time.
The study
itself was quasi-experimental. To be included in the study, patients had to 1)
have knee or hip arthritis, 2) ) be continuously enrolled in the Group Health
Plan for 12 months prior to the orthopedic clinic visit and 3) have a visit
itself that was first index visit by the patient for that problem being
evaluated by that particular specialty.
Outcomes from
the 18 months of the SDM intervention period (January 2009 through July of
2010) were compared to the observation period of January 2007 through July of
2008.
Recall that
the surgeon had to proactively order the SDM prior to the visit. As a result,
only 41% of the hip patients and 28% of the knee patients received the DVD,
pamphlet or viewed the on-line materials.
Nonetheless,
during the 6 months after the initial visit, the SDM patient population had
0.34 hip operations per 180 person-days (your DMCB offers an explanation of
this counter-intuitive metric below*), compared to the control population of
0.46. The difference was statistically significant.
There was
also a statistically significant reduction in knee operations: 0.09 per 180
person-days vs 0.16 per 180 person-days.
All the
differences held up after the authors statistically adjusted for differences in
age, sex, obesity, co-morbid conditions, use of prior x-rays, joint injections,
insurance factors and the clinic site.
Like all good
authors writing in a high quality journal, they point out that this research
was not pristine. The comparison period may not have been a representative
baseline and, from 2008 to 2009, other factors may have caused a drop in hip
and knee surgeries.
Nonetheless,
this is an example of a “real world” study that credibly demonstrates that when
osteoarthritis patients are exposed to SDM, more will opt for conservative
management. While that helps decrease health care utilization and ultimately
costs, that’s not the most important point: the patients who really wanted
surgery got it and the patients who were less sure about the benefits of
surgery chose not to have it. What’s more, this didn’t involve a lot of
expensive face-to-face care management, it involved some DVDs.
The DMCB
cautions that this successful study was carried out in a highly integrated
delivery system and may not be transferable to other practice settings. That
being said, as Accountable Care Organizations struggle to meet their patients’
expectations and save money, this application of SDM may represent an important
option.
*The DMCB
interprets “180 patient days” as one patient being followed for the entire 6
months of the study. If that’s correct, the average SDM knee patient referred
to a Group Health orthopedist had a 34% chance of getting surgery versus a 46%
chance in the prior control group. For the knee patients, it was 9% vs. 16%.
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