Shared Decision-Making Aids Reduce Surgeries and Save Money for Unexpected Reasons

Hip replacement surgeries declined by 26 percent and knee replacement surgeries fell by 38 percent at five clinics using shared decision-making devices, according to the report of a study posted on the Agency for Healthcare Research and Quality Innovation Exchange Website.  The costs of treating hip osteoarthritis fell by 21 percent, and the cost of treating knee osteoarthritis fell by 12 percent at the clinics using shared decision-making devices.  However, the majority of the decline did not come from patients who used the shared decision-making devices.  Conversations with surgeons who worked at the clinics suggested that the intense provider education, training and motivation that was part of the program was more influential in the outcomes  than the decision-making aid.  It appears that  the mere presence of the program at these clinics resulted in physicians engaging in more conversations with patients about treatment options and patients who did not use the aid actually chose to have less surgery.

Shared Decision-Making

Shared decision-making is a collaborative process between patients and physicians to promote and help the patient and provider choose the most effective level of care for that patient. Shared decision-making devices are educational tools that help patients and caregivers understand and communicate their beliefs and preferences related to their medical care.  The Patient Protection and Affordable Care Act (PPACA)(P.L. 111-148) requires the HHS Secretary to implement a program to develop shared decision-making devices and provides grants for the establishment and use of shared decision-making. PPACA defines a shared decision-making device as one that  (1) is designed to engage patients in  informed decision-making with their health care provider; (2) presents up-to-date clinical evidence about the risks and benefits of treatment options in a form and manner that is appropriate to the patient’s age and culture; (3) explains why the evidence supports one treatment option over another; and (4) addresses health care decisions for all, including vulnerable populations and children.

In this study the decision-making aid was a video with accompanying written material.  The patients were supposed to receive the decision-making aid before their first visit with the specialist.  If the patient did not receive or use the aid, the physician would order one during the initial visit. The doctors instructed the patients that using the decision-making aid would be essential to the next conversation about their treatment.  Some patients were able to access the decision-making aid via the internet and some had the material mailed to their home.

Hip and Knee Surgery

The integrated health system chose to test the effectiveness of the shared decision-making device with potential hip and knee replacement patients.   Over 1 million hip or knee replacement surgeries are conducted each year.  The annual cost for all these surgeries is estimated to be $15.6 billion.   The high number of these surgeries performed and the disagreement among professionals as to which patients will benefit from them make the treatment decision an excellent subject of study.

During the 18 months that the study was conducted, 41 percent of eligible patients with hip osteoarthritis and 28 percent  of the patients with knee osteoarthritis received a decision aid.  Although distribution of the aid was mandatory, many physicians did not order it until surgery was likely, a fact to which the studies authors attribute  the surprising finding that those who used the decision-making aid actually were more likely to undergo  surgery.  Of the people who viewed and used the decision-making aid, the hip replacement patients were 44 percent more likely to have surgery and patients with arthritic knees were 103 percent more likely to choose surgery.

In spite of this finding, the overall surgery rate at these five clinics dropped dramatically when compared to other clinics and the population at large.  The studies authors attribute this to the intense provider education and increased communication between patients and physicians during the early phase of the disease.  It appears that the program helped people in early stages who were less likely to have surgery simply because the program was in place.