A QUALITY IMPROVEMENT STUDY TO INTEGRATE PATIENT DECISION AIDS INTO ORTHOPEDIC CARE

Purpose: The study focused on designing and deploying a sustainable method of decision aid (DA) delivery within a busy orthopedics department for hip and knee osteoarthritis, herniated disc, and spinal stenosis. 

Methods: There were three phases for the DA integration project. First, we used a formal department quality improvement (QI) bonus to generate awareness of and interest in using DAs among specialists.  Second, we focused on internal referrals (i.e. coming from a primary care provider (PCP) within our hospital system) and adapted our electronic clinical referral management system (CRMS) to enable PCPs to place the DA order at the time of referral to a specialist for these topics. Third, we focused on external referrals and worked with each specialist and their staff to define and implement a reliable workflow. Our target was to reach 60% of eligible patients with DAs. We tracked the number of eligible patients who received a DA for each topic in each phase. 

Results: After the first phase, 23% (36/155) of eligible spine patients and 33% (102/310) of eligible hip/knee patients received a DA. The majority of patients received the DAs after the visit and many remarked that they wished they had the DA before the visit. In the second phase, 57% (67/118) of spine referrals and 60% (194/324) of hip/knee referrals in CRMS included a DA order.  These patients received the DA before the visit; however, internal referrals represented less than half of the specialists’ new patient volume. In the third phase, hip/knee schedulers ordered DAs for new patients in advance of scheduled visits. Spine specialists continued to order DAs during the visit for patients, because it was not possible to confirm eligiblity in advance. In the third phase, we reached 48% (79/163) of eligible spine patients and 67% (206/307) of eligible hip/knee patients. 

Conclusions: Integration of DAs into clinic workflow is an intensive process that requires engaging providers and staff. The QI bonus was helpful in raising interest in the DAs but did not lead to significant usage. Connecting the DA order to the referral process was well received and effective in reaching patients before the visit.  The redesigned workflows were also effective in increasing usage, and current efforts are focused on maintaining these levels.