2.1 Study Design and Patient Population
This retrospective study draws upon data from patients diagnosed with
hip or knee osteoarthritis who received care within one of 10 High Value
Healthcare Collaborative (HVHC) systems. HVHC is a provider learning
collaborative of health systems from across the United States that share
data pertaining to multiple quality improvement projects with the aim of
elevating the provision of high value, evidence-based patient
care.21 The 10 member systems of HVHC include: Baylor
Health System, Beth Israel Deaconess Medical Center, Denver Health,
Eastern Main Healthcare Systems, Intermountain Healthcare, MaineHealth,
Mayo Clinic, Scott and White Health, UCLA Health System, and Virginia
Mason Medical Center. Data from each HVHC system was analyzed during the
three-year period (from July 1, 2012 to June 30, 2015) when HVHC
received a grant entitled “The High Value Healthcare Collaborative:
Engaging Patients to Meet the Triple Aim” from the Center for Medicare
and Medicaid Innovation (CMMI) to facilitate the routine use of decision
aids to support SDM among patients with hip or knee
osteoarthritis.22
Adult (age 18-86) patients with diagnoses of hip (International
Classification of Diseases, Clinical Modification codes (ICD-9 CM)
diagnostic codes 715.09, 715.15, 715.25, 715.35 or 715.95) or knee
(ICD-9 CM diagnostic codes 715.09, 715.16, 715.26, 715.36 or 715.96)
osteoarthritis who were exposed to decision aids within HVHC systems and
for whom complete post-decision aid surveys assessing patient choices
were completed prior to the end of the CMMI grant period (June 30, 2015)
were included. Among 1,791 hip and knee osteoarthritis patients who were
exposed to decision aids and completed post-decision aid patient
surveys, a total of 1,351 expressed a post-decision aid treatment choice
of either surgical or non-surgical intervention (n = 974 knee patients
and n = 377 hip patients). Since the outcome of interest was alignment
between post-decision aid treatment choice and treatment received,
patients who expressed uncertainty after receiving decision aids (n =
440) were excluded.
HVHC’s grant-funded project made use of decision aids (specific for hip
or knee osteoarthritis) meant to support SDM conversations between
clinicians and patients and pre- and post-decision aid web-based
questionnaires. For both hip and knee osteoarthritis patients, HVHC
provider systems utilized Health Dialog-produced decision aids. Health
Dialog decision aids meet standards set by the International Patient
Decision Aid Standards Collaborative 23 and provide
balanced information about treatment options for conditions including
hip and knee osteoarthritis. Patients were invited to view decision aids
online, on DVD, or on a tablet in the orthopedic surgeon’s office either
prior to or following their consultations. Before and after viewing the
decision aids, patients completed surveys that assessed their treatment
choices, decision-making stage, and gathered information including
patients’ education, insurance status, and self-assessed pain (as
measured by the pain sub-scale of the Knee Injury and Osteoarthritis
Outcome Score (KOOS) and Hip Injury and Osteoarthritis Outcome Score
(HOOS) for knee and hip osteoarthritis patients, respectively).
For patients who viewed decision aids in the medical office prior to
their appointment, health coaches - who in most cases were registered
nurses – were available to answer questions regarding the decision aids
and patient surveys. Health coaches received decision support training
sponsored by the collaborative through a 4-week distance learning course
that incorporated “active learning assignments” building upon the
Ottawa Personal Decision Guide tools and framework.24During the patient’s orthopedic appointment, the orthopedic surgeon
could review survey responses, clarify questions, and address patient
concerns that may not have been answered by the decision aid alone. The
adoption of decision aids among HVHC systems was motivated by the
collaborative’s focus upon improving overall functioning of patients
considering hip or knee surgery and ensuring that rates of such
surgeries reflected patient treatment preferences.