4.0 Discussion
In light of growing calls to consider the important outcome of care reflective of patients’ preferences, this work contributes to the patient engagement literature by examining the odds of alignment between patient-expressed treatment choices and treatments received among patients within systems belonging to a learning collaborative that sought to integrate the utilization of decision aids to support SDM into routine clinical practice. The majority of patients with hip (71.9%) or knee (68.3%) osteoarthritis in this study who chose surgical or non-surgical treatment after exposure to decision aids received treatment aligned with their preference. These findings echo other musculoskeletal-focused research by Sepucha et al, who found that 73% of patients with hip or knee osteoarthritis who were considering surgical intervention received treatments that were aligned with their personal goals and values.28
Notably, this study highlights that the odds of patients with hip or knee osteoarthritis receiving treatments aligned with their post-decision aid treatment choices differ across patient-level characteristics. Among patients with knee osteoarthritis, those who were Medicare or Medicaid beneficiaries had lower odds of alignment between their treatment choices and treatments received compared with patients who were privately insured. Another important finding was that Black or African American patients with knee osteoarthritis had lower odds of choice-treatment receipt alignment relative to white patients, and this finding persists when looking at the regression findings limited to the patients who chose surgery. Although it is beyond the scope of this study to determine why these gaps may exist, research that has investigated patient preferences in the context of osteoarthritis has shown that disparities in access to care, treatment expectations and socioeconomic factors play critical roles in treatment trajectories - especially for diverse patient populations and those with public health
insurance. 29,30 Several studies have underscored persistent gaps in the likelihood of Black or African American patients receiving arthroplasty compared with white patients,31,32 with some research pointing to the cost of surgery as a major barrier to care for Black patients.33 Elsewhere, a longitudinal survey of respondents to the U.S. Health and Retirement Study found that Medicare recipients with supplemental coverage were more likely to receive knee arthroplasty than patients with traditional Medicare only, suggesting that the lack of such additional coverage may pose a barrier to the financial feasibility of receiving surgery.34 These factors may also underlie the gaps in choice-treatment receipt alignment among Black or African American patients or those with Medicare whose preference was for surgery, although additional research is needed to confirm this. It is worth highlighting that the representative sample of Black or African American patients with hip or knee osteoarthritis cohorts among HVHC systems was small (8% of the knee osteoarthritis population and 6.4% of the hip osteoarthritis population within HVHC), which underscores the importance of studying these questions within the context of more diverse patient population as systems determine how best to integrate tools such as decision aids into routine clinical practice.
Among patients with knee or hip osteoarthritis, this study also found that those at earlier decision-making stages after viewing decision aids had lower odds of receiving treatments congruent with their choices compared with patients at later stages. For patients who were still considering their options after viewing decision aids, there may be more opportunities to be swayed toward alternative treatment choices by physicians, family or friends, or through additional research. More advanced decision-making stages have been linked with higher decision quality and greater confidence in treatment choices28; conversely, there may be an association between earlier decision-making stages and less confidence in treatment choices that could prompt additional conversations to discuss preferences (whether the patient’s or the physician’s) and expectations about treatment outcomes that in turn alter final treatment choices.
For conditions such as hip and knee osteoarthritis, shared decision-making can play an important role in facilitating alignment between patients’ expressed choices and treatments reflective of those choices. Although critical to the SDM process, the use of decision aids to support shared decision-making and to help patients make informed treatment decisions does not necessarily guarantee alignment between patient-expressed treatment choices and the treatments they receive. Decision aids represent “only one part of the shared decision making process, and the provider plays a key role in helping patients synthesize information so they make the most informed, appropriate decision in the context of their own values and goals.”2 Elsewhere, it has been noted that even in situations where high quality decision aids are utilized, communicating “patient-accessible information” may not always result in alignment between patient preferences and treatment plans.35Importantly, other factors beyond information shared via decision aids can ultimately influence patients’ treatment trajectories, including physicians’ treatment
preferences.18 Additionally, conversations with family, caretakers, or clinicians may highlight patient characteristics (such as comorbidities that might make patients unsuitable candidates for surgery) or other factors (such as concerns about the length and difficulty associated with recovery time) that could nudge patients toward treatments that differ from their original choices after use of decision aids.8
Understanding how decision aids and related patient engagement strategies facilitate outcomes of interest including congruence between treatment choice and treatment receipt across important sub-groups of patients remains an important question related to this research. Embedding value-clarification exercises with decision aids has been suggested as an important tool to ensure that prior to treatment receipt, patients’ treatment choices are truly reflective of their personal values and goals.36 Patient-centered strategies including motivational interviewing and health coaching may also play pivotal roles alongside decision aids in ensuring better understanding of treatment options as well as other key outcomes such as decisional regret or satisfaction.37 Recently, there is particular interest in studying how decision aids can be used to support effective doctor-patient communication to bridge gaps in care for racial or ethnic minority patient groups.38Longitudinal, prospective studies that examine the impact of routinely implemented decision aids complemented by value clarification or motivational interviewing could further shed light upon important patient-reported outcomes including choice-congruent treatment39, and would be especially valuable if studied in the context of diverse patient populations to provide insight into how such tools could best be tailored to meet the needs of these groups.
Since this analysis examined alignment between treatment choices after exposure to decision aids and treatments received among patients within 10 health systems belonging to a learning collaborative, there are important limitations of this research. First, the findings may not be reflective of health systems beyond this sample – especially smaller systems or those with less experience with patient-centered quality improvement. Nonetheless, the relative dearth of work examining alignment between patient treatment choices and treatment receipt after the routine integration of a decision aid intervention across multiple geographically diverse systems underscores the novelty of this research. Since this data was collected as part of an implementation study, it was not feasible to measure the extent to which patients engaged in SDM with nurses or clinicians alongside exposure to decision aids due to a lack of documentation by participant systems, nor was it possible to construct a comparison group since patient treatment choices were only assessed for those exposed to decision aids. Finally, since system-reported clinical files were utilized to determine receipt of treatment, this analysis cannot account for patients potentially receiving treatments (whether aligned or not aligned with their choices) at non-HVHC systems. However, given that this sample of patients completed patient surveys pertaining to their viewing of decision aids and had documented consultations with orthopedists within HVHC systems, the likelihood that many such patients would have received orthopedic treatments at non-collaborative health systems is likely low.
This study elucidates the association between patient-level characteristics and the odds of alignment between patients’ expressed treatment choices and treatments received after exposure to decision aids that were routinely implemented across a learning collaborative of health systems. For the population of patients with hip or knee osteoarthritis who were the focus of this study, being Black or African American (compared with white patients), being Medicare beneficiaries (compared with those who were privately insured), and not being certain of a treatment choice following exposure to decision aids were associated with lower odds of alignment between patient treatment choices and treatments received. Specifically examining the odds of alignment between treatment choice and receipt among patients who chose surgery for either hip or knee osteoarthritis uncovered similar results. Taken together, these findings underscore the important role of patient-level characteristics in determining congruence between patients’ choices after a decision aid and receipt of aligned treatments. As health systems seek to integrate decision aids into routine practice, understanding why certain patient-level characteristics are associated with such congruence while others are not and how decision aids and shared decision-making conversations could realistically be tailored to meet the needs of different patient groups should be a key area for future research. Such a question is central to implementing patient-focused strategies to bridge current gaps and to better align all patients’ preferences with the treatments they ultimately receive.
Acknowledgements: The author is a Member of the High Value Healthcare Collaborative (HVHC), a consortium of healthcare delivery systems sharing data and experiences to improve quality, outcomes, and cost of care. The views expressed are those of the authors and not necessarily those of all the participating HVHC Members.
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