Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons

INTRODUCTION

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting.

METHODS

With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids.

RESULTS

We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73–85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model.

CONCLUSIONS

Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.     

A standardized analysis of the current surgical and non-surgical treatment selection process for men with localized prostate cancer

Robot-assisted radical prostatectomy to treat localized prostate cancer has increased in popularity, although other options exist, including radiotherapy and active surveillance. The decision about choosing the right treatment has become pertinent for many patients. This literature review aimed to assess the current state-of-the-art regarding decisional aids and the associated decisional outcomes for the purpose of designing a method for both patients and doctors to use to make the best treatment decision for the patient. A literature search was conducted via MEDLINE, Embase, and Web of Science databases using the keywords “prostate” and “cancer” and “impact” and “decisio*” and “treatment.” Articles were included that focused on treatment outcomes, decision-making processes, and the use of decisional aids for localized prostate cancer. Articles that investigated prostate cancer in general or prostate cancer screening were excluded, as were articles that were not written in English. Altogether, 13 articles were finally critically reviewed for this study. Results were conflicting regarding the relations between patient factors, use of decisional aids, and decisional outcomes. There was a large gap in the literature regarding the optimal decision-making process for men with localized prostate cancer. The role of currently available decisional aids is limited to helping patients make the right decisions. There is a need to develop a novel decisional aid in which patient–physician discussion—involving evaluation of a spectrum of patient-, doctor-, and treatment-related factors—is included.     

Incorporating patient preferences into orthopaedic practice: should the orthopaedic encounter change?

The issues concerning treatment decision-making are that often options for treatment lead to uncertain outcomes (benefits and risks) at the individual patient level and that both patients and physicians might value these outcomes differently. There are three main approaches commonly used to describe treatment decision-making including paternalistic, shared and informed decision-making. The challenge and responsibility of physicians is to effectively communicate to patients that they should feel welcome to participate in decision-making through whichever approach seems suitable to them. Changes in laws governing the ethics of medical practice mandate a more comprehensive decision-making tactic requiring a two-way flow of information between patient and physician. The key to information exchange lies in evoking patient preferences by informing the patient of the benefits and risks associated with each treatment option. Decision aids have been developed in a variety of forms to facilitate this transfer of information about available treatment alternatives in as unbiased fashion as possible. We believe that treatment options presented should include not only those available by the particular physicians at that institution but also those available at outside institutions and within other healthcare systems. We discuss barriers for physicians who wish to encourage patient participation such as the power differential that exists between patients and physicians, factors related to health policy, and those unique to surgery. We believe that investigation is necessary to understand how the differences between types of medical practices, or even within a medical field, will influence the importance that patients attach to having their values and preferences considered during treatment decision-making and to evaluate how this importance changes as the severity of adverse events associated with treatment outcomes changes. We feel that it is important for physicians and surgeons to begin to think about these issues and how they might investigate potential resolutions for incorporating patient values and sharing their own preferences for treatment options with their patients during the orthopaedic encounter.     

Can nomograms be superior to other prediction tools?

Accurate estimates of the likelihood of treatment success, complications and long-term morbidity are essential for counselling and informed decision-making in patients with urological malignancies. Accurate risk estimates are also required for clinical trial design, to ensure homogeneous patient distribution. Nomograms, risk groupings, artificial neural networks (ANNs), probability tables, and classification and regression tree (CART) analyses represent the available decision aids that can be used within these tasks. We critically reviewed available decision aids (nomograms, risk groupings, ANNs, probability tables and CART analyses) and compared their ability to predict the outcome of interest. Of the available decision aids, nomograms provide individualized evidence-based and highly accurate risk estimates that facilitate management-related decisions. We suggest the use of nomograms for the purpose of evidence-based, individualized decision-making.     

A systematic review of decision aids for patients making a decision about treatment for early breast cancer

Several complex treatment decisions may be offered to women with early stage breast cancer, about a range of treatments from different modalities including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids can facilitate shared decision-making and improve decision-related outcomes. We aimed to systematically identify, describe and appraise the literature on treatment decision aids for women with early breast cancer, synthesise the data and identify breast cancer decisions that lack a decision aid.A prospectively developed search strategy was applied to MEDLINE, the Cochrane databases, EMBASE, PsycINFO, Web of Science and abstract databases from major conferences. Data were extracted into a pre-piloted form. Quality and risk of bias were measured using Qualsyst criteria. Results were synthesised into narrative format.Thirty-three eligible articles were identified, evaluating 23 individual treatment decision aids, comprising 13 randomised controlled trial reports, seven non-randomised comparative studies, eight single-arm pre-post studies and five cross-sectional studies. The decisions addressed by these decision aids were: breast conserving surgery versus mastectomy (+/− reconstruction); use of chemotherapy and/or endocrine therapy; radiotherapy; and fertility preservation. Outcome measures were heterogeneous, precluding meta-analysis. Decisional conflict decreased, and knowledge and satisfaction increased, without any change in anxiety or depression, in most studies. No studies were identified that evaluated decision aids for neoadjuvant systemic therapy, or contralateral prophylactic mastectomy.Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids for neoadjuvant systemic therapy and contralateral prophylactic mastectomy could not be found, and may be warranted.     

ICU患者替代决策者决策疲劳现象学研究

目的 分析ICU患者替代决策者的决策疲劳体验，为医护人员实施决策辅助提供参考。方法 采用目的抽样法，对12名ICU患者替代决策者进行半结构式访谈, 采用Colaizzi分析法进行资料分析及主题提炼。结果 ICU患者替代决策者存在决策疲劳，可归纳为5个主题：决策能力有限，负性情绪加剧，决策过程中的困境，决策过程中的冲突和决策支持资源不足。结论 ICU患者替代决策者者面临决策疲劳，医护人员应针对替代决策者决策疲劳采取干预措施，以推进决策辅助支持及共享决策的实施，提高决策质量，改善患者结局。     

Therapie des nichtmetastasierten Prostatakarzinoms

Background

Patients with nonmetastatic prostate cancer face a complex treatment decision. To support them with personalized information, a variety of interactive computerized decision aids have been developed in Anglo-Saxon countries. Our goal was to identify relevant decision aids and investigate their didactic strengths and limitations.

Materials and methods

We included decision aids that derived individualized content from personal and clinical data provided by the patient. By conducting a systematic literature and internet research through November 2013 supplemented by expert interviews, we identified 10 decision aids of which 6 had been investigated scientifically. We compared their individual characteristics as well as the design and results of the evaluation studies.

Results

The decision aids present two to seven therapy choices, whereby radical prostatectomy and percutaneous radiotherapy are always included. Number and type of parameters provided by the patient also vary considerably. Two decision aids derive a therapeutic recommendation from the patient’s input. Evaluation studies showed higher disease-related knowledge and greater confidence in the treatment decision after using one of six decision aids. Satisfaction with the decision aid was predominantly high.

Conclusions

Currently personalized patient decision aids for treatment of nonmetastatic prostate cancer are only available in English. These tools can facilitate the shared decision making process for patients and physicians. Therefore, comparable decision aids should be developed in German.     

Counselling the Prostate Cancer Patient

ContextPatient involvement in the medical decision-making process has gained a good deal of importance during the last decades. It has become widely accepted that patient values and preferences should also be considered during treatment selection when reasonable alternatives are available.ObjectiveThis paper discusses the process of shared medical decision making and the importance of informing the patient and improving patient–physician communication concerning prostate cancer (PCa).Evidence acquisitionDuring a satellite symposium at the European Association of Urology (EAU) 2008 annual meeting, the issue of shared medical decision making in PCa was presented. This paper discusses the most important messages of this presentation, supported by recent findings in the literature.Evidence synthesisIn clinical situations where data do not clearly differentiate the treatment alternatives, patient involvement in the medical decision-making process becomes critical. Therefore, patient–physician communication should be emphasised, and physicians should take the time necessary to inform the patient about potential treatment options and their expected consequences. Increasing a patient’s ability to engage physicians in a dialogue and providing patients with balanced information will contribute to a well-considered decision, which in turn can minimise future regret. Misleading information on the Internet and poor literacy skills can hamper the decision-making process. Patients are often dissatisfied with inadequate time spent during physician visits and the not-uncommon perception that treatment choices the physician presents are more restricted than optimal.ConclusionsIn current clinical practice, the patient–physician dialogue should be enhanced, and patients’ preferences should be taken into consideration in the decision-making process. This will contribute to well-considered treatment decisions and improve patient satisfaction.     

Evidence-based orthopaedic surgery: what is evidence without the outcomes?

With the increased emphasis on evidence-based medicine in orthopaedics, the surgeon is faced with the challenge of evaluating the effectiveness of various treatment interventions. Health care authorities are also interested in measuring competing interventions, but out of concern for controlling costs. The success or failure of an intervention is often determined based on treatment outcomes. There are many outcomes measures available in the orthopaedic literature, and it is not uncommon for different measures to produce conflicting results. The orthopaedic surgeon must have the ability to accurately evaluate an outcomes measure to determine the value of a specific intervention. Similarly, selecting the appropriate outcomes measure for research or clinical purposes is an important decision that may have far-reaching implications on reimbursement and determining treatment success. To best select outcomes measures and to select the appropriate treatment for each patient, the orthopaedic surgeon needs to understand the recommended contents of a quality instrument, the difference between clinician-based and patient-reported outcomes, and how to evaluate outcomes reported in the literature.     

Potential cost-effectiveness for using patient decision aids to guide osteoporosis treatment

Summary

We use a model to predict whether using a patient decision aid in patients considering bisphosphonate therapy would be a good use of health resources. We found that if the decision aid improved adherence, and only marginally increased time physicians needed with their patients, then the decision-aid would be cost-effective.

Introduction

Oral bisphosphonates have been shown to reduce the risk of osteoporotic fracture. Adherence is crucial but suboptimal. A recent study suggests that a patient decision aid, which facilitates shared decision-making, could be effective in increasing adherence to bisphosphonates. But decision aids come at a cost in terms of additional time spent with physicians. This study considers the emerging evidence on the role of patient decision aids in improving adherence to bisphosphonates and their potential costs to inform future decision-making and research priorities.

Methods

We estimate the hypothetical cost-effectiveness of a patient decision aid detailing the benefits and risks of bisphosphonates for osteoporotic patients, from a Canadian healthcare perspective. A previously developed and validated Markov microsimulation model was adapted to include use of a patient decision aid to support the decision of whether to initiate bisphosphonate therapy, and subsequent influence on adherence and future fractures. We considered 2014 costs and benefits in terms of quality-adjusted life-years (QALYs).

Results

A patient decision aid that could improve treatment initiation rates or persistence (adherence) by 20 %, or a linear combination of the two, in osteoporotic women aged 70+ over a 3-year treatment period was found to have an incremental cost-effectiveness ratio below $50,000/QALY.

Conclusions

Patient decision aids have the potential to be cost-effective in osteoporosis so long as they increase adherence under certain conditions. Funding further research on the long-term effectiveness and costs of a patient decision aid which outlines all treatment options for osteoporosis patients is justified.

     

Shared decision-making in peri-operative medicine: a narrative review

This review on shared decision-making comes at a time when international healthcare policy, domestic law and patient expectation demand a bringing-together of the patient's values and preferences with the physician's expertise to determine the best bespoke care package for the individual. Despite robust guidance in terms of consent, the anaesthetic community have lagged behind in terms of embracing the patient-focused rather than doctor-focused aspects of shared decision-making. For many, confusion has arisen due to a conflation of informed consent, risk assessment, decision aids and shared decision-making. Although they may well be linked, they are discrete entities. The obstacles to delivering shared decision-making are many. Lack of time is the most widely cited barrier from the perspective of physicians across specialties, with little time available to the anaesthetist at the day-of-surgery pre-operative visit. A more natural place to start the process may be the pre-operative assessment clinic, especially for the ‘high-risk’ patient. Yet shared decision-making is for all, even the ‘low-risk’ patient. Another barrier is the flow and the focus of the typical anaesthetic consultation; the truncated format presents the danger of a cursory, ‘time-efficient’ and mechanical process as the anaesthetist assesses risk and determines the safest anaesthetic. As patients have already decided to proceed with therapy or investigation and may be more concerned about the surgery than the anaesthesia, it is often assumed they will accept whatever anaesthetic is offered and defer to the clinician's expertise – without discussion. Furthermore, shared decision-making does not stop at time of anaesthesia for the peri-operative physician. It continues until discharge and requires the anaesthetist to engage in shared decision-making for prescribing and deprescribing peri-operative medicines.     

Advanced decision-making using patient-reported outcome measures in total joint replacement

Up to one-third of total joint replacement (TJR) procedures may be performed inappropriately in a subset of patients who remain dissatisfied with their outcomes, stressing the importance of shared decision-making. Patient-reported outcome measures capture physical, emotional, and social aspects of health and wellbeing from the patient's perspective. Powerful computer systems capable of performing highly sophisticated analysis using different types of data, including patient-derived data, such as patient-reported outcomes, may eliminate guess work, generating impactful metrics to better inform the decision-making process. We have created a shared decision-making tool which generates personalized predictions of risks and benefits from TJR based on patient-reported outcomes as well as clinical and demographic data. We present the protocol for a randomized controlled trial designed to assess the impact of this tool on decision quality, level of shared decision-making, and patient and process outcomes. We also discuss current concepts in this field and highlight opportunities leveraging patient-reported data and artificial intelligence for decision support across the care continuum.     

Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science

BackgroundGuidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities.MethodsThe purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care.ResultsIn this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool.ConclusionsWe provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.     

Communicating prognosis in the dialysis consent process: a patient-centered, guideline-supported approach

Recent guidelines recommend shared decision making between patients and nephrologists as the model for dialysis decision making. A key component of this shared decision making is obtaining informed consent. As part of this process, nephrologists have an obligation to inform patients with chronic kidney disease of their prognosis. Ideally, patients themselves should be involved in the decision-making process; however, some patients will not possess decision-making capacity, and others may be unwilling to participate. Determining what to tell patients about prognosis requires tailoring the conversation to the individual patient's preferences. Conversations about prognosis need to occur in a timely fashion so that patients have the opportunity to consider options and make decisions before dialysis is inevitable. Communication strategies are available to assist nephrologists in breaking the bad news of the need for dialysis and its associated burdens. The approach described in this article should help nephrologists discuss prognosis with their patients in a way that is patient centered and in accordance with clinical practice guideline recommendations.     

Der ältere Prostatakrebspatient

Introduction

Some data exist on information and decision-making preferences of elderly prostate cancer patients but little is known about whether communication needs are being met in urological practice. Therefore, it was the aim of this study to examine the information and shared decision-making experiences of prostate cancer patients over 75 years old.

Materials and methods

The HAROW (hormonal therapy, active surveillance, radiation, operation and watchful waiting) study is a prospective, observational study designed to collect clinical data and patient reported outcome of different treatment options for patients newly diagnosed with localized prostate cancer under real conditions. At 6-month intervals general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. Data from 2,482 patients at 4 time points from T0 (initial diagnosis) to T3 (24 months follow-up) were analyzed.

Results

T-tests and χ²-tests revealed no significant differences in terms of shared decision-making and information to different treatment options between patients aged over 75 years old and the rest of the sample. Regarding information on self-help groups, rehabilitation options and a second medical opinion, there were significant differences between prostate cancer patient age groups: patients aged over 75 years old received less information on these aspects at all points in time.

Conclusion

Patients at all ages feel activated by urologists and are informed about different treatment options. However, there is room for improvement in terms of informing especially elderly prostate cancer patients about rehabilitation, second medical opinions and self-help groups. Special information tools and decision aids for prostate cancer patients aged over 75years old should be developed and implemented to meet the specific information needs.     

Challenges in Outcome Measurement: Discrepancies Between Patient and Provider Definitions of Success

Background

Some orthopaedic procedures, including TKA, enjoy high survivorship but leave many patients dissatisfied because of residual pain and functional limitations. An important cause of patient dissatisfaction is unfulfilled preoperative expectations. This arises, in part, from differences between provider and patient in their definition of a successful outcome.

Where Are We Now?

Patients generally are less satisfied with their outcomes than surgeons. While patients are initially concerned with symptom relief, their long-term expectations include return of symptom-free function, especially in terms of activities that are personally important. While surgeons share their patients’ desire to achieve their goals, they are aware this will not always occur. Conversely, patients do not always realize some of their expectations cannot be met by current orthopaedic procedures, and this gap in understanding is an important source of discrepancies in expectations and patient dissatisfaction.

Where Do We Need to Go?

An essential prerequisite for mutual understanding is information that is accurate, objective, and relevant to the patient’s condition and lifestyle. This critical information must also be understandable within the educational and cultural background of each patient to enable informed participation in a shared decision making process. Once this is achieved, it will become easier to formulate similar expectations regarding the likely level of function and symptom relief and the risk of adverse events, including persistent pain, complications, and revision surgery.

How Do We Get There?

Predictive models of patient outcomes, based on objective data, are needed to inform decision making on the individual level. This can be achieved once comprehensive data become available capturing the lifestyles of patients of diverse ages and backgrounds, including data documenting the frequency and intensity of participation in sporting and recreational activities. There is also a need for greater attention to the process of informing patients of the outcome of orthopaedic procedures, not simply for gaining more meaningful consent, but so that patients and providers may achieve greater alignment of expectations and increased acceptance of both the benefits and limitations of alternative treatments.     

Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Patient expectations have been shown to be an independent predictor of outcomes in clinical medicine. In the orthopaedic literature, the majority of studies have focused on the relationship between pre-operative expectations and post-operative outcomes in patients undergoing total hip arthroplasty, total knee arthroplasty, shoulder surgery, and spine surgery. Various methodologies have been used to assess patient expectations in orthopaedic surgery, including direct questioning, short questionnaires, and validated surveys. Multiple patient factors have been associated with greater expectations prior to elective orthopaedic surgery, and greater pre-operative expectations have been shown to be associated with better subjective and objective outcomes after total hip and knee arthroplasty, shoulder surgery, and spine surgery. While there are very few validated measures of patient satisfaction after orthopaedic surgery, increased post-operative patient satisfaction is consistently associated with meeting pre-operative patient expectations. Given the relationship between pre-operative patient expectations and post-operative outcomes and patient satisfaction, understanding and defining expectations prior to elective orthopaedic surgery may optimize outcomes. In this review, we aim to summarize the current literature on patient expectations in orthopaedic surgery.     

Consumer impact of an interactive decision aid for rectal cancer patients offered adjuvant therapy

OBJECTIVE: There is increasing interest in the use of decision aids (DAs) to facilitate patient involvement in clinical decisions. This study explored the views of patients with colorectal cancer and participants in a community bowel screening service regarding an interactive DA concerning adjuvant treatment for rectal cancer, and the impact of the aid on knowledge, anxiety, attitudes and preferences for treatment options. METHOD: Fourteen patients with colorectal cancer participated in four focus groups. Eighty-nine participants in a community bowel screening service completed a questionnaire before and 1 week after viewing the DA. Thirty were randomly selected to participate in a telephone interview to obtain qualitative feedback about the DA. RESULTS: Focus group participants reported using information to evaluate their doctor's care and expertise, or to prepare themselves for future symptoms and side-effects. Most supported the use of a DA and preferred pie charts to convey risk information. Within the community sample, anxiety remained stable and knowledge increased after exposure to the DA. Almost all participants found the DA useful and easy to understand, and felt it would make the process of decision making easier. CONCLUSION: A DA regarding adjuvant therapy for rectal cancer appears to be valued and to produce positive outcomes. A randomized controlled trial of this intervention is now required.     

A survey of breast cancer physicians regarding patient involvement in breast cancer treatment decisions

PurposeShared breast cancer treatment decision-making between patients and physicians increases patient treatment satisfaction and compliance and is influenced by physician-related factors. Attitudes and behaviors about patient involvement in breast cancer treatment decisions and treatment-related communication were assessed by specialty among breast cancer physicians of women enrolled in the Breast Cancer Quality of Care Study (BQUAL).ResultsOf 275 BQUAL physicians identified, 50.0% responded to the survey. Most physicians spend 46–60 min with the patient during the initial consult visit and 51.5% report that the treatment decision is made in one visit. Oncologists spend more time with new breast cancer patients during the initial consult (p = 0.021), and find it more difficult to handle their own feelings than breast surgeons (p = <0.001).ConclusionBreast surgeons and oncologists share similar attitudes and behaviors related to patient involvement in treatment decision-making, yet oncologists report more difficulty managing their own feelings during the decision-making process.