“Medical decision science is a field that encompasses several related pursuits,” wrote the authors of the 2008 article “Medical Decision Making: A Physician’s Guide.” “As a normative endeavor, it proposes standards for ideal decision making. As a descriptive endeavor, it seeks to explain how physicians and patients routinely make decisions, and has identified both barriers to, and facilitators of, effective decision making. As a prescriptive endeavor, it seeks to develop tools that can guide physicians, their patients, and healthcare policymakers to make good decisions in practice.”
Medical decision aids focused on patient inclusion in the decision-making process help physicians and patients explore together the benefits and risks of each treatment option. By including the patient more closely in the decision-making process, decision aids also help improve patient knowledge and ultimately the quality of care they receive.
The Society for Medical Decision Making (SMDM) is dedicated to improving health outcomes and fostering research for medical decision making. Two papers presented at the 2017 SMDM conference were especially relevant for orthopaedic surgeons and their patients. The first was “Prevalence and Predictors of Knee Replacement Overuse and Underuse in the U.S.” This cohort study sought to determine the rates of total knee replacement (TKR) utilization and investigate predictors of overuse and underuse. According to author Hassan Ghomrawi, PhD, MPH, it is one of the first studies to attempt to quantify TKR overuse and underuse in the United States.
Using data from the Osteoarthritis Initiative and the Multicenter Osteoarthritis Study, the researchers divided 3,500 patients with knee osteoarthritis into three groups: appropriate TKR users, potential TKR underusers, and potential TKR overusers. They characterized the disparities among the groups using validated appropriateness criteria. “We found both TKR overuse (8.5 percent) and underuse (67.4 percent). Among the underusers, 43 percent had significant pain that could have been improved with surgery,” Dr. Ghomrawi said.
Furthermore, “Being [African-American] was the strongest predictor of underuse, corroborating prior findings; however, contrary to prior findings, we did not see any gender differences in TKR use. Recognizing that there may be factors beyond the current study that may cause patients to be overusers or underusers, we are currently conducting further studies to understand the reasons underlying their status,” he said.
More research is needed to further characterize the differences in under- and overuse, and to discover potential ways for correcting the discrepancies. Ultimately, decision aids may play a valuable role in helping patients make the correct decisions about their care.
To effectively facilitate this decision making, the appropriate information needs to be made available to the patient. In his paper “Layperson Advice Regarding Design, Content, and Use of Decision Aids: A Public Deliberation,” Peter H. Schwartz, MD, sought to understand what types of quantitative information were important to patients when making decisions about their medical care. To find out, Dr. Schwartz and his fellow researchers assembled a demographically random group of laypeople to educate them on the topic of colorectal cancer screening. The individuals were then surveyed about what decision-aid information they felt would be most helpful.
“To be useful, decision aids have to be understandable and directly applicable to the decision at hand. They should be ‘tailored’ to the people using them; for instance, letting people choose how much or little information they wanted to receive,” Dr. Schwartz said.
He went on to highlight the key role clinicians can play in the effective usage of decision aids. “Nothing is going to replace the importance of patients talking to their trusted healthcare providers, but decision aids can help patients prepare for these conversations. Healthcare providers should make decision aids available to their patients,” he said.
Dr. Schwarz also believes that “clinicians should identify aids they like and can recommend to their patients” noting that “we can all learn more about the hard choices that patients face, and how best to frame those choices and inform patients.”
In this vein, AAOS has developed Appropriate Use Criteria (AUC), which use evidence-based clinical practice guidelines and physician experience to rate the appropriateness of various procedures for an array of orthopaedic diseases. For each disease, the AUC tool enables the surgeon and patient to construct the patient’s disease profile and receive the most suitable treatment recommendations based on existing evidence and clinician consensus. The AUC tool is available at www.OrthoGuidelines.org or as a free app download in the Google Play or Apple Stores.
Decision-making aids give patients the opportunity to be more active in their health care. By providing them with point-of-care materials, patients are able to have more focused conversations with their physicians about treatment options. Decision aids are an important aspect of medical decision-making and will play a crucial role in the future of orthopaedic care.
Danielle Schulte, MS, and Nicole Nelson, MPH, are evidence-based medicine research analysts in the AAOS department of Research, Quality, and Scientific Affairs.
Schwartz and Bergus, Medical Decision Making: A Physician's Guide, Cambridge University Press, 2008).