Impact of Educational and Patient Decision Aids on Decisional Conflict Associated with Total Knee Arthroplasty

University of Texas MD Anderson Cancer Center, Houston, USA.
Arthritis care & research 02/2012; 64(2):229-37. DOI: 10.1002/acr.20646
Source: PubMed


To examine the impact of a videobooklet patient decision aid supplemented by an interactive values clarification exercise on decisional conflict in patients with knee osteoarthritis (OA) considering total knee arthroplasty.
A total of 208 patients participated in the study (mean age 63 years, 68% female, and 66% white). Participants were randomized to 1 of 3 groups: 1) educational booklet on OA management (control), 2) patient decision aid (videobooklet) on OA management, and 3) patient decision aid (videobooklet) + adaptive conjoint analysis (ACA) tool. The ACA tool enables patients to consider competing attributes (i.e., specific risks/benefits) by asking them to rate a series of paired comparisons. The primary outcome was the decisional conflict scale ranging from 0-100. Differences between groups were analyzed using analysis of variance and Tukey's honestly significant difference tests.
Overall, decisional conflict decreased significantly in all groups (P < 0.05). The largest reduction in decisional conflict was observed for participants in the videobooklet decision aid group (21 points). Statistically significant differences in pre- versus postintervention total scores favored the videobooklet group compared to the control group (21 versus 10) and to the videobooklet plus ACA group (21 versus 14; P < 0.001). Changes in the decisional conflict score for the control group compared to the videobooklet decision aid + ACA group were not significantly different.
In our study, an audiovisual patient decision aid decreased decisional conflict more than printed material alone or the addition of a more complex computer-based ACA tool requiring more intense cognitive involvement and explicit value choices.

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    • "Findings in one randomized controlled trial (RCT) revealed that compared to controls (n = 62) patients who used this PtDA (n = 61) felt more informed and confident in what to ask their doctor; the surgeons reported greater satisfaction and efficiency with the consultation and indicated that patients exposed to the PtDA asked more appropriate questions [23]. The other trial showed lower decisional conflict in those exposed to the PtDA (n = 70) compared to the PtDA with an adaptive conjoint analysis (n = 69) or educational booklet (n = 69) [24]. "
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    ABSTRACT: To evaluate feasibility and potential effectiveness of a patient decision aid (PtDA) for patients and a preference report for surgeons to reduce wait times and improve decision quality in patients with osteoarthritis considering total knee replacement. A prospective two-arm pilot randomized controlled trial. Patients with osteoarthritis were eligible if they understood English and were referred for surgical consultation about an initial total knee arthroplasty at a Canadian orthopaedic joint assessment clinic. Patients were randomized to the PtDA intervention or usual education. The intervention was an osteoarthritis PtDA for patients and a one-page preference report summarizing patients' clinical and decisional data for their surgeon. The main feasibility outcomes were rates of recruitment and questionnaire completion; the preliminary effectiveness outcomes were wait times and decision quality. Of 180 patients eligible for surgical consultation, 142 (79%) were recruited and randomized to the PtDA intervention (n = 71) or usual education (n = 71). Data collection yielded a 93% questionnaire completion rate with less than 1% missing items. After one year, 13% of patients remained on the surgical wait list. The median time from referral to being off the wait list (censored using survival analysis techniques) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) and 33.0 weeks for usual education (n = 71, 95% CI: 26.1, 39.9). Patients exposed to the PtDA had higher decision quality based on knowledge (71% versus 47%; p < 0.0001) and quality decision being an informed choice that is consistent with their values for option outcomes (56.4% versus 25.0%; p < 0.001). Recruitment of patients with osteoarthritis considering surgery and data collection were feasible. As some patients remained on the surgical waiting list after one year, follow-up should be extended to two years. Patients exposed to the PtDA achieved higher decision quality compared to those receiving usual education but there was no difference in wait for surgery.Trials registration: ClinicalTrials.Gov NCT00743951.
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    ABSTRACT: Recent scientific advances in the treatment of hip and knee osteoarthritis (OA) relating to education, exercise, weight control and passive non-pharmacological and non-surgical treatments such as manual therapy, orthoses/orthotics and other aids are described. A systematic literature search was performed in Medline from July 2011 to 10 April 2012 using the terms 'osteoarthritis, knee', 'osteoarthritis, hip' rehabilitation, physical therapy, exercise therapy and preoperative intervention; both as text words and as MeSH terms where possible. Trials evaluating rehabilitation interventions were included if they were randomized controlled trials (RCTs) or systematic reviews. Outcome papers were identified by combining the initial search with the terms 'outcome', 'measure*', 'valid*', 'reliabil*' or 'responsiveness'. Outcome studies were included if they contributed methodologically to advancing outcome measurement. The literature search identified 550 potentially relevant papers. Seventeen RCTs on rehabilitation were selected and the results from these were supported by six systematic reviews. Sixteen outcomes papers were considered relevant, but did not add significantly to current knowledge about outcome measures in OA and so, were not included. The current research focus on non-pharmacological and non-surgical treatments for hip and/or knee OA, when combined in systematic reviews, is improving the available evidence to identify best practice treatment. Education, exercise and weight loss are effective in the long term and supported as cost-effective first-line treatments.
    Osteoarthritis and Cartilage 09/2012; 20(12):1477-83. DOI:10.1016/j.joca.2012.08.028 · 4.17 Impact Factor
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    ABSTRACT: BACKGROUND: Decision making in knee osteoarthritis, with many treatment options, challenges patients and physicians alike. Unfortunately, physicians cannot describe in detail each treatment's benefits and risks. One promising adjunct to decision making in osteoarthritis is adaptive conjoint analysis (ACA). OBJECTIVE: To obtain insight into the experiences of elderly patients who use adaptive conjoint analysis to explore treatment options for their osteoarthritis. DESIGN: Participants, all 65 and older, completed an ACA decision aid exploring their preferences with regard to the underlying attributes of osteoarthritis interventions. We used focus groups to obtain insight into their experiences using this software. RESULTS: Content analysis distributed our participants' concerns into five areas. The predicted preferred treatment usually agreed with the individual's preference, but our participants experienced difficulty in four other domains: the choices presented by the software were sometimes confusing, the treatments presented were not the treatments of most interest, the researchers' claims about treatment characteristics were unpersuasive and cumulative overload sometimes developed. CONCLUSION: Adaptive conjoint analysis presented special challenges to our elderly participants; we believe that their relatively low level of computer comfort was a significant contributor to these problems. We suggest that other researchers choose the software's treatments and present the treatment attributes with care. The next and equally vital step is to educate participants about what to expect, including the limitations in choice and apparent arbitrariness of the trade-offs presented by the software. Providing participants with a sample ACA task before undertaking the study task may further improve participant understanding and engagement.
    Health expectations: an international journal of public participation in health care and health policy 09/2012; 17(6). DOI:10.1111/j.1369-7625.2012.00811.x · 3.41 Impact Factor
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