Decision Aid Implementation and Patients' Preferences for Hip and Knee Osteoarthritis Treatment: Insights from the High Value Healthcare Collaborative.

Background:Shared decision making (SDM) research has emphasized the role of decision aids (DAs) for helping patients make treatment decisions reflective of their preferences, yet there have been few collaborative multi-institutional efforts to integrate DAs in orthopedic consultations and primary care encounters. Objective:In the context of routine DA implementation for SDM, we investigate which patient-level characteristics are associated with patient preferences for surgery versus medical management before and after exposure to DAs. We explored whether DA implementation in primary care encounters was associated with greater shifts in patients' treatment preferences after exposure to DAs compared to DA implementation in orthopedic consultations. Design:Retrospective cohort study. Setting:10 High Value Healthcare Collaborative (HVHC) health systems. Study participants:A total of 495 hip and 1343 adult knee osteoarthritis patients who were exposed to DAs within HVHC systems between July 2012 to June 2015. Results:Nearly 20% of knee patients and 17% of hip patients remained uncertain about their treatment preferences after viewing DAs. Older patients and patients with high pain levels had an increased preference for surgery. Older patients receiving DAs from three HVHC systems that transitioned DA implementation from orthopedics into primary care had lower odds of preferring surgery after DA exposure compared to older patients in seven HVHC systems that only implemented DAs for orthopedic consultations. Conclusion:Patients' treatment preferences were largely stable over time, highlighting that DAs for SDM largely do not necessarily shift preferences. DAs and SDM processes should be targeted at older adults and patients reporting high pain levels. Initiating treatment conversations in primary versus specialty care settings may also have important implications for engagement of patients in SDM via DAs

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation

Abstract Background A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis. Methods The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined. Results In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not. Conclusions The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals

Decision Aid Implementation and Patients' Preferences for Hip and Knee Osteoarthritis Treatment: Insights from the High Value Healthcare Collaborative.

BackgroundShared decision making (SDM) research has emphasized the role of decision aids (DAs) for helping patients make treatment decisions reflective of their preferences, yet there have been few collaborative multi-institutional efforts to integrate DAs in orthopedic consultations and primary care encounters.ObjectiveIn the context of routine DA implementation for SDM, we investigate which patient-level characteristics are associated with patient preferences for surgery versus medical management before and after exposure to DAs. We explored whether DA implementation in primary care encounters was associated with greater shifts in patients' treatment preferences after exposure to DAs compared to DA implementation in orthopedic consultations.DesignRetrospective cohort study.Setting10 High Value Healthcare Collaborative (HVHC) health systems.Study participantsA total of 495 hip and 1343 adult knee osteoarthritis patients who were exposed to DAs within HVHC systems between July 2012 to June 2015.ResultsNearly 20% of knee patients and 17% of hip patients remained uncertain about their treatment preferences after viewing DAs. Older patients and patients with high pain levels had an increased preference for surgery. Older patients receiving DAs from three HVHC systems that transitioned DA implementation from orthopedics into primary care had lower odds of preferring surgery after DA exposure compared to older patients in seven HVHC systems that only implemented DAs for orthopedic consultations.ConclusionPatients' treatment preferences were largely stable over time, highlighting that DAs for SDM largely do not necessarily shift preferences. DAs and SDM processes should be targeted at older adults and patients reporting high pain levels. Initiating treatment conversations in primary versus specialty care settings may also have important implications for engagement of patients in SDM via DAs

Utility of quantitative computerized pain drawings in a sample of spinal stenosis patients

To evaluate the utility of quantitative computerized pain drawings (CPDs) in a sample of spine patients before and after surgery. Analysis of changes in quantified CPDs, the Oswestry Disability Index (ODI), the Short Form-36 Health Survey Questionnaire (SF-36), and numerical ratings of pain intensity before and after surgery. Private clinic in large metropolitan area. Patients. Forty-six patients with spinal stenosis. Interventions. Surgery for the relief of pain due to spinal stenosis. A total points (TP) score was calculated from the CPD that reflected the total number of pixels filled by the patient, and the percentage of total pain area indicated as aching, stabbing, numbness, pins and needles, burning, and other, were each calculated separately. CPD scores, ODI score, Physical Components Summary (PCS) and Mental Components Summary scores of the SF-36, and pain intensity ratings (0-10 scale) were all recorded before and after surgical intervention. Results. After surgery, patients showed significant improvements in the extent of shaded pain area of the CPD, pain intensity ratings, ODI, and SF-36 PCS scores (paired t-test, P < or = 0.01). Changes in TP scores calculated from the CPDs were significantly correlated (P < or = 0.05) with changes in ODI scores (r = 0.34) and pain intensity ratings (r = 0.37). Changes in the percentage of total pain area covered by specific qualities of pain were not significant. Results from the present study provide initial support for the use of automated quantified data collected from CPDs to evaluate treatment interventions and to serve the clinician as a record of changes in spatial location, radiation or extent of pain, and the sensory quality of pain when evaluating individual patient needs

sj-jpg-1-vmj-10.1177_1358863X241237776 – Supplemental material for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease

Supplemental material, sj-jpg-1-vmj-10.1177_1358863X241237776 for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease by Stanislav Henkin, Stephen A Kearing, Pablo Martinez-Camblor, Nikolaos Zacharias, Mark A Creager, Michael N Young, Philip P Goodney and Jesse A Columbo in Vascular Medicine</p

sj-docx-1-vmj-10.1177_1358863X241237776 – Supplemental material for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease

Supplemental material, sj-docx-1-vmj-10.1177_1358863X241237776 for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease by Stanislav Henkin, Stephen A Kearing, Pablo Martinez-Camblor, Nikolaos Zacharias, Mark A Creager, Michael N Young, Philip P Goodney and Jesse A Columbo in Vascular Medicine</p

sj-jpg-2-vmj-10.1177_1358863X241237776 – Supplemental material for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease

Supplemental material, sj-jpg-2-vmj-10.1177_1358863X241237776 for The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease by Stanislav Henkin, Stephen A Kearing, Pablo Martinez-Camblor, Nikolaos Zacharias, Mark A Creager, Michael N Young, Philip P Goodney and Jesse A Columbo in Vascular Medicine</p