1. Introduction
Shared decision-making (SDM) and the use of patient decision aids are
frequently highlighted as important tools for fostering patient
engagement across conditions ranging from early stage breast cancer1 to musculoskeletal conditions,2and are associated with positive impacts upon patient-centered outcomes
including decision satisfaction and quality in multiple studies.3-5 Research suggests that decision aids used in the
context of SDM are associated with reduced anxiety, less regret and
better health outcomes compared with usual care. 6Elsewhere, decision aids have been shown to support patients in making
treatment choices consistent with their values - especially when there
is clinical equipoise between such choices, as is the case for
preference sensitive conditions. 7
Hip and knee osteoarthritis are two such preference sensitive
musculoskeletal conditions for which current clinical evidence does not
necessarily demonstrate superiority of surgery (arthroplasty) over
non-surgical medical management (physical therapy, use of non-steroidal
anti-inflammatory medications), 8 and the choice
between these treatment options is likely to vary according to patient
characteristics and personal values. 9 Additionally,
these treatment options come with differing costs, side effects, and
risks, 10 further underscoring the importance of
patients being provided with information that empowers them to make
informed, value-aligned treatment choices.11 As the
costs of care for patients living with musculoskeletal conditions
continues to rise (in 2014, direct costs for these conditions was
estimated to be $980.1 billion in the United States alone) and as the
prevalence of patients with hip and knee osteoarthritis continues to
grow,12 so does the imperative for health systems to
engage patients in conversations about treatment option benefits and
tradeoffs such as through the use of decision aids intended to support
SDM.
Recent scholarship in the field of SDM has underscored that the
alignment between patients’ expressed treatment choices and treatments
received represents a critical component of decision
quality,13 14 which is defined as
“the extent to which patients are informed, meaningfully involved in
the decision-making process, and receive tests and treatments that
reflect their goals and concerns.”15 Although such
alignment has been recognized as an important outcome of SDM,16 some research shows that alignment between patient
treatment choice and treatment receipt is not always achieved; in one
large multi-year research trial of SDM among patients with low back
pain, nearly one quarter of those patients electing for medical
management received surgical interventions instead. 7Sullivan et al examined treatment choices of patients diagnosed with
stage 1 lung cancer and found a lack of congruence between
patient-expressed treatment choices and treatments received among 49%
(n = 114) of study
participants.17 Scherr et al note that treatment
choice may be dictated by other factors (such as physician rather than
patient preferences) even where SDM has occurred.18 In
addition to the clear gaps that exist in achieving alignment with
patient expressed treatment choices, much of this research has focused
upon patient populations drawn from single institutions or health
systems.18,19
This paper explores the extent of alignment between patient-expressed
treatment choices after exposure to decision aids and treatments
received among hip and knee osteoarthritis patients within High Value
Healthcare Collaborative (HVHC) systems while the collaborative sought
to integrate SDM into routine clinical practice. Specifically, this work
investigates which patient-level characteristics are associated with
alignment between treatment choice and treatment received among patients
diagnosed with hip or knee osteoarthritis within HVHC exposed to
decision aids for these conditions. These analyses importantly examine
such alignment in the context of patients drawn from diverse health
systems in a learning collaborative,20 and in the
context of routine implementation of decision aids to support SDM in
clinical practice as opposed to a controlled trial setting. The aim of
this study is to understand the associations between patient-level
characteristics and alignment in expressed choices and treatments
received for hip or knee osteoarthritis after a decision aid
intervention.