Laird Harrison

March 22, 2017

SAN DIEGO — Two-thirds of patients considering orthopedic surgery are not well informed, which can lead to unwanted treatments and poorer outcomes, according to results from a new study.

"We tend to overestimate how much people understand about their disease and treatments," said Karen Sepucha, PhD, from Massachusetts General Hospital in Boston, who presented the results here at the American Academy of Orthopaedic Surgeons 2017 Annual Meeting.

Major orthopedic guidelines recommend that physicians and patients collaborate on decisions, such as whether to opt for surgery or a more conservative treatment, but few studies have examined the consequences of failing to do so.

To look at the issue, Dr Sepucha and her colleagues assessed patients with knee or hip osteoarthritis, lumbar herniated disc, or lumbar spinal stenosis who were candidates for surgical or nonsurgical treatments.

The 551 study participants completed a survey at baseline and at 6 months. Average age was 63.9 years, 52.8% of the patients were women, 92.4% were white, and 62.9% had a college degree.

We tend to overestimate how much people understand about their disease and treatments.

At their initial consultation, patients received information about treatment options. A week later, they completed a survey about their preferred option and a test about their condition and available treatments. The 6-month questionnaire assessed outcome and quality of life.

Of the study cohort, 49.0% underwent surgery in the 6 months after the initial visit.

Patients who answered at least 60% of the test questions correctly and were treated with their preferred option were considered to have made an "informed patient-centered decision."

Just 46% of the patients answered at least 60% correctly, and just 36% met the criteria for an informed patient-centered decision. It is not unusual to find such a high percentage of patients who do not make well-informed decisions, Dr Sepucha reported.

At 6 months, 70% of patients said they received the treatment they wanted. Of the remaining 30%, most wanted surgery but did not get it.

Better-Informed Patients, Better Outcomes

Informed patients were significantly more likely to report being "extremely satisfied" with their treatment (71% vs 35%; P = .0003) and with the degree of pain they experienced (77% vs 42%; P = .0003). They were also significantly less likely to express regret about their decision (5% vs 15%; P = .0006).

Scores for knee, hip, and osteoarthritis outcomes and quality-of-life measures were slightly but significantly better for informed than for less-informed patients.

People who were informed and received their preferred treatment tended to do better.

"People who were informed and received their preferred treatment tended to do better," Dr Sepucha told Medscape Medical News.

Despite general agreement that patients should actively participate in treatment decisions, it is not clear why this leads to better outcomes, she noted.

"We don't know the mechanisms for the effect; that will be important to study in future work," she explained. "It could be that these patients have more realistic expectations or that they are more motivated to follow through with the treatment."

Cost Remains a Hurdle

If patients are involved in treatment decisions, "they have some buy-in," said John Cherf, MD, from Advocate Health Care in Chicago.

However, he noted, "economics comes into play with all these decisions," and cost was not considered in this study. Patients who have high deductibles and copayments might be less satisfied with the treatments they receive, he pointed out.

He also noted that the study population — from Boston, which generally has a more educated population and higher cost of care — might not be representative of the overall population in the United States.

Dr Sepucha and her colleagues were surprised to find that some patients who initially expressed a preference for nonsurgical treatment underwent surgery. They could have changed their minds after receiving additional information from the surgeon, the researchers point out.

Study Underlines the Importance of Patient Education

This study underlines the importance of educating patients and understanding what they consider to be a successful outcome, said Harry Rubash, MD, also from Massachusetts General Hospital, who was one of the study investigators.

"Joint camp" classes have been used to educate orthopedic patients at Advocate Health Care, Dr Cherf reported. However, the classes are expensive to provide and some patients find it difficult to attend. To overcome these obstacles, the course content is now provided in digital form.

"I hope more of our specialties adopt these types of programs to better inform patients," Dr Rubash said. "This is a first foray into orthopedics. I'd like to see other sites doing this."

The need for patient education extends beyond orthopedics. "In studies that have examined shared decision-making — not just in orthopedics, but also for statins, cancer, and other treatments — you often find gaps in patients' knowledge," Dr Sepucha explained. "They are often not able to answer questions you would think they could."

Dr Sepucha reports a financial relationship with Healthwise. Dr Cherf reports financial relationships with Allergan, Galderma, SkinBetter, Amgen, Cerner, Imogen, CVS, McKessen, Teva, Immunomedics, Stericycle, Merck, Eli Lilly, Innomed, Johnson & Johnson, Medtronic, Pfizer, and Wolters Kluwer Health. Dr Rubash reports financial relationships with CeramTec, Flexion, Orthopedic Technology Group, Pacira Pharmaceuticals, Stryker, and Wolters Kluwer Health.

American Academy of Orthopaedic Surgeons (AAOS) 2017 Annual Meeting: Abstract P126. Presented March 14, 2017.


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