SHARED DECISION MAKING IN ORTHOPEDIC CARE ENHANCES HEALTH OUTCOMES: A PROSPECTIVE COHORT STUDY

Purpose: Many clinical guidelines promote shared decision making (SDM), though few studies have been adequately powered to detect impact of SDM on health outcomes. The purpose of this study was to examine whether patients who are well-informed and receive preferred treatment have better health outcomes.

Method: A prospective cohort study enrolled eligible patients with knee or hip osteoarthritis, lumbar herniated disc (LDH) or spinal stenosis (LSS). Participants were surveyed one week after their visit with a specialist to assess knowledge, preferred treatment, and baseline quality of life (QoL) (EQ-5D, Knee injury and Osteoarthritis Outcome Score (KOOS), Harris Hip Score, Oswestry Disability Index (ODI)). Patients with a passing knowledge score (60% or higher) who received their preferred treatment (either surgery or non surgical) were considered to have made an informed, patient-centered (IPC) decision.

A follow-up survey at six months assessed QoL, regret and satisfaction. We tested hypotheses that patients who made IPC decisions would have higher QoL, higher satisfaction and less decision regret at follow-up. Regression analyses accounted for clustering of patients within clinicians and controlled for surgery, age, gender, joint and baseline QoL.  With 550 surveys the study had more than 80% power to detect a difference of 0.05 on the EQ-5D between those who made IPC decision or not.

Result: The response rate to the initial survey was (652/926, 70.3%) and to the follow up survey was (551/648, 85%). About half received a decision aid (45.5%) and about half had surgery (49.0%) within the 6 months of the initial visit. Patients who made IPC decisions (36.0%) reported significantly better overall and disease-specific QoL, across all topics. The unadjusted  increase was 0.06 for EQ-5D, p=0.006,  4.72 points for KOOS symptoms, p=0.009, 2.93 points for Harris Hip Score p<0.0001, and  -7.59 points on ODI p<0.0001.  Participants who made IPC decisions were more likely to be extremely satisfied with improvement in symptoms (76.68% vs. 41.86%, p=0.0003), more likely to be very or extremely satisfied with treatment (70.68% vs. 34.66%, p=0.0003), and had less regret (5.2% vs. 15.0% p=0.0006).

Conclusion: Patient engagement in elective surgery decisions is important ethically, and evidence from this study suggests that well-informed patients that receive their preferred treatment have higher satisfaction and small improvements in health outcomes.