1. Do patient decision aids reduce wait times and improve quality of decisions for patients considering TJA? A randomized controlled trial University of Ottawa, Ottawa Hospital Research Institute; University of Toronto and Women’s College Hospital; Dartmouth College, New Hampshire; University of Montreal October 2014 D Stacey, G Dervin, M Taljaard, I Tomek, P Tugwell, A O’Connor, G Hawker Funding: Informed Medical Decisions Foundation

2. Outline Standardized screening process Evaluation of first year of patients screened Effectiveness of patient decision aid

3. The Ottawa Hospital Orthopedic Intake Clinic –Launched in December 2006 –staffed by 1 of 4 MSK physicians TOH Joint Screening Clinic

4. ....

5. Conner-Spady B, Estey A, Arnett G, Ness K, McGurran J, Bear R et al. Prioritization of patients on waiting lists for hip and knee replacement: validation of a priority criteria tool. Int J Technol Assess Health Care 2004; 20(4):509- 515

6. NIH criteria for knee replacement 1.Radiographic evidence of joint damage 2.Moderate to severe persistent pain that is not adequately relieved by an extended course of non-surgical management 3.Clinically significant functional limitation resulting in diminished quality of life NIH Consensus Development Conference Statement - Total Knee Replacement. http://consensus.nih.gov/2003/2003TotalKneeReplacement117html 2003. http://consensus.nih.gov/2003/2003TotalKneeReplacement117html

8. Outline Standardized screening process Evaluation of first year of patients screened Effectiveness of patient decision aid

9. * Other: walking aid (33), acupuncture (2), exercise (2), massage (1), wheelchair (1), physiatrist(1)

10. Results Apr 07 – Mar 08 47.4% referred back to family physician 52.6% surgeon consult 327 patients screened 81.4% surgery 18.6% no surgery - other health issues (7) - patient decision (6) - symptoms resolved (6)

11. Referred to Surgeon (N=172) Not Referred to Surgeon (N=155) P value Age (mean; SD)67 (10.6)63 (11.2)N/S Percent female65.7%62.6%N/S BMI (mean; SD)33.3 (6.5)33.3 (7.4)N/S Medication tried93.0%91.0%N/S Injections tried58.7%32.3%<0.001 Physiotherapy tried33.1%36.8%N/S Tried 3 or more measures18.6%11.0%0.01 Met 3 NIH criteria86.5%33.3%<0.001 WOMAC (96 points) (mean; SD) 56.2 (17.)846.5 (21.5)<0.001 HKPT (80 points) (mean; SD) 44.8 (15.6)23.9 (14.1)<0.001 Results

12. Summary Underuse of conservative measures prior to referral Use of sport med physicians and screening tools resulted in ~50% reduction in surgical consultations Most patients referred on to surgeon received surgery Patients with milder OA need management in the community

13. Outline Standardized screening process Evaluation of first year of patients screened Effectiveness of patient decision aid

14. Usual care/education Hospital booklet on joint replacement Summary report of clinical priority sent to surgeon Participants were randomized to + Patient Decision Aid Patient decision aid: DVD and booklet from Health Dialog Patient decision guide (knowledge, clarity of values, preference) Summary report of patient preference (and clinical priority) sent to surgeon ®

16. 16 Stacey, D. et al. BMJ 2008;0:bmj.39520.701748.94v2-bmj.39520.701748.94 Copyright ©2008 BMJ Publishing Group Ltd. BMI=27

17. Participant characteristics Decision Aid (n=167) Usual Care (n=167) Hip (n)4745 Knee (n)120122 Age (mean years)66.166.9 Men (n)7864 Women (n)89103 Education: Less than high school(n) 11 13 High/trade/technical school (n)7670 College (n)3224 University/graduate degree (n)4860 Living arrangements: live alone (n)39 44 live with someone else (n)128123 Employment full time(n)31 33 part time (n)1218 retired (n)105106 other (n)1118 Income/ <20,000 to <20,000 to Year>100,000 >100,000

18. Wait times : PtDA 118 days (95% CI: 109 to 140) Usual 144 days (95% CI: 121 to 164)

19. Achieving decision quality (knowledge score >66%; values predicting actual choice +50%) RR 1.25 (95% CI 1.0 to 1.6)

20. Actual decision Had surgery No Surgery Loopback surgery Patient Decision Aid (n=164) 73.2%19.5%7.3% Usual Care (n=164) 80.5%14.6%4.9% Surgery: Mantel Haenszel 0.91 (95% CI 0.8-1.0) Loopback: Mantel Haenszel 1.11 (95% CI 0.5-2.5)

21. Process of decision making ItemsPatient decision aid Usual care P-values Knowledge (out of 100)68.9%61.1%<0.001 Feel informed93.6%79.6%<0.001 Feel clear about values88.5%79.6%0.046 Feel supported in making choice85.3%80.3%No diff Feel sure about best choice70.5%76.4%No diff Know decision depends on values5 of 54 of 50.003 Help prepare to talk to doctor5 of 54 of 50.014 Help recognize a decision needs to be made 4 of 5 No diff Help think about how involved they want to be 5 of 5 No diff 4-items SURE test (Decisional Conflict) 4-items Preparation for Decision Making Scale

22. Summary of Findings Appears to be shorter wait in the patient decision aid group plus preference report for their surgeon (compared to usual care) Patient decision aid group had higher decision quality, felt more informed, clear about what matters most, prepared to discuss their values for outcomes of options with the surgeon, and knew that the decision depended on what mattered most to them. Overall, patient decision aids improved the process of decision making and resulted in higher decision quality

23. http://decisionaid.ohri.ca