Decision Aid Increases Knee Replacements Among Black Patients

Troy Brown, RN

December 02, 2016

A video decision aid significantly increased the percentage of black patients with knee osteoarthritis (OA) who underwent total knee replacement (TKR) by 85% compared with a typical educational pamphlet, according to a new randomized, multicenter study.

The video also increased the likelihood of receiving a recommendation for TKR from an orthopedic surgeon by almost a third, but this association was not statistically significant.

"Patient-centered educational tools such as decision aids might help reduce racial disparities in access to preference-sensitive surgical treatments such as total knee replacement," the researchers write.

Said A. Ibrahim, MD, MPH, from the Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, both in Philadelphia, Pennsylvania, and colleagues published their findings online November 23 in JAMA Surgery.

Osteoarthritis is a leading cause of disability in the United States, with a prevalence among black adults at least as high as that among white adults. However, previous studies have shown that black patients undergo TKR at a significantly lower rate than their white peers, despite its demonstrated benefits.

To try to reduce the dispartity, Dr Ibrahim and colleagues enrolled 336 black patients aged 50 years or older with chronic, frequent knee pain on the basis of the National Health and Nutrition Examination Survey questionnaire, a Western Ontario McMasters University Osteoarthritis score of 39 or higher, and radiographic evidence of knee OA.

The study excluded patients with prior major joint replacement, terminal illness, physician-diagnosed inflammatory arthritis, prosthetic leg, cognitive impairment, lack of home telephone service, or contraindications to elective replacement surgery.

Patients were randomly assigned to the intervention group (n = 168), which included viewing a 40-minute video describing the risks and benefits of TKR surgery, or a a control group (n = 168), which included receiving a standard educational brochure. The study's main outcomes were receipt of TKR surgery within 12 months of the intervention and/or TKR surgery recommendation from an orthopedic surgeon within 6 months after the intervention.

In the intention-to-treat (ITT) analysis, 7.7% (n = 13 of 168 patients) in the control group and 14.9% (n = 25 of 168 patients) in the intervention group underwent surgery within 12 months of the intervention. In the per-protocol analysis, 7.1% (n = 11 of 154 patients) and 15.3% (n = 23 of 150 patients) in the control group and the intervention group, respectively, underwent surgery within 12 months of the intervention (P = .02).

In the ITT analysis, 15.5% (n = 26) of patients in the control group and 20.2% (n = 34) of patients in the intervention group received a recommendation for surgery within 6 months (P = .25). However, in the per-protocol analysis, the surgery recommendation rate did not differ significantly between the control group (15.6%; n = 24 of 154) and the intervention group (20.7%; n = 31 of 15). Results were similar after adjustment for study site.

"Decision aids provide high-quality information on treatment options while also clarifying the outcomes of treatment choice. In this way, they empower patients and facilitate communication and decision making," the authors write. "Decision aids are associated with increased patient knowledge, more realistic patient perceptions about the disease or treatment, less decisional conflict, fewer patients who are passive decision makers, fewer patients who remain indecisive after counseling, and improved concordance between patient values and treatment choices."

Dr Ibrahim reports receiving a Mid-Career Development Award from the National Institute of Arthritis and Musculoskeletal and Skin Disorders. The remaining coauthors have disclosed no relevant financial relationships.

JAMA Surg. Published online November 23, 2016. Abstract

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