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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