Shared Decision Making in Orthopaedic Surgery: More Than Two to Tango?: Commentary on an article by Kevin J. Bozic, MD, MBA, et al.: “Shared Decision Making in Patients with Osteoarthritis of the Hip and Knee. Results of a Randomized Controlled Trial”
第一作者：Terence J. Gioe
2013-11-20 点击量：435 我要说
Orthopaedic surgeons have had relatively little exposure to shared decision-making tools in their practice. First popularized in a 1982 report issued by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research1, shared decision making is generally viewed as an embodiment of the principle of patient-centered care, with shared decisions between patients and providers often facilitated by decision and communication aids. Charles et al.2 identified the characteristics of shared decision making as involving the patient and provider, both parties participating in the treatment decision-making process, requiring information sharing, and both parties agreeing to the treatment decision made, with the recognition that many of these characteristics are continuous variables. The authors of the present study have previously made important contributions to our understanding of how shared decision making might be incorporated into orthopaedic practice, with both attendant benefits and obstacles to overcome3,4.
Knee and hip osteoarthritis treatment includes both medical and surgical interventions often managed by orthopaedists, and when pain and disability are unresponsive to medical treatment, total joint arthroplasty is frequently recommended. Total joint arthroplasty is appropriately viewed as a preference-sensitive procedure, as the indications are driven by the patients’ perception of pain, quality of life, and expectations of improvement offered by the surgery. Utilization rates vary widely on the basis of geography, sex, age, and ethnicity, but patients’ willingness to undergo surgery, patients’ fear of complications, or differences in surgeon practice patterns may also influence this variation4. The authors of this report accurately point out that shared decision-making tools may have gained little favor in orthopaedic practice because of surgeons’ concerns that patients will be less likely to choose surgery, or issues centered around the cost, logistics, and efficiency of implementing shared decision-making models in practice.
Bozic et al. attempt to address some of these concerns in this well-designed randomized controlled trial of shared decision making in candidates for total joint arthroplasty in two academic centers. After initial prescreening, patients were randomized into two groups, an intervention group and a control group. The intervention group was mailed a decision aid consisting of a digital video disc (DVD) and a booklet outlining treatment alternatives in hip and knee osteoarthritis. Each patient in the intervention group was also provided a consultation with a health coach who helped the patient formulate pertinent questions, attended the appointment with the patient, and subsequently provided the patient with a recording of the appointment and a copy of the dictated consultation note. Control subjects received directions to the clinic and a brief handout about hip and knee osteoarthritis and treatment options. Both groups, as well as the surgeons, completed preconsultation and postconsultation surveys. Briefly summarized, the patients in the intervention group were more knowledgeable about risks, benefits, and alternative treatments; were further advanced in their decision-making process; and had more confidence in their questions posed to the surgeon than patients in the control group. Surgeons similarly believed that the intervention group asked more appropriate questions and used their time more efficiently. There was no significant difference in the time spent in consultation between the two groups, nor was there a significant difference in the choice of operative versus nonoperative management between the groups following the consultation—an important finding.
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