When doctors suggest that their hip and knee replacement candidate patients view decision tools before they undergo surgery, 38% fewer people went ahead with the knee procedure and 26% fewer agreed to undergo hip replacement.
Over a six-month period, total costs were 12% to 21% lower as well.
Those are the findings from an article in the September issue of the journal Health Affairs from researchers for Group Health Cooperative in Seattle. The team looked to see what happened when 27 staff surgeons and 15 physician assistants regularly suggested that surgical candidates use the tools, either on an online website or a mailed DVD before making the decision about having the surgery.
Use of decision tools give patients independent information about the risks and benefits of their procedures, including complication rates and recovery periods, and help them set realistic expectations for their improved healthcare quality.
Because the tools may prompt many patients to decline procedures, they may affect care models that do not employ doctors more than those that use a salaried structure.
"We saw a large shift in rates of surgery and costs of care after introducing decision aids," says David Arterburn, associate investigator at Group Health Research Institute and principal investigator of the study, which asked 27 staff surgeons and 15 physician assistants who see patients in five specialty clinical sites located in Seattle, Bellevue, Tacoma, Olympia and Silverdale to distribute the tools.
Arterburn and his colleagues at Group Health pointed to "strong evidence from prior research that most patients are not well-informed of their treatment choices or their likely outcome probabilities at the time that they make major medical decisions."
The two decision tools, which were developed by the Informed Medical Decision Foundation in Boston and Health Dialog, explain to patients details of the surgery they are about to have, what non-surgical options exist, what life-style changes they could make, and what physical therapy and walking aids or pain medications, or complementary and alternative therapies might be selected instead of surgery.
A section under surgical treatment choices goes into detail about the various kinds of surgery, such as the types of artificial hip joints, types of surgery incisions, or hip resurfacing.
The researchers looked at the choices made by 1,720 patients with hip osteorarthritis and 7,727 patients with knee osteoarthritis. In the hip group, 820 patients were given the tools while the rest were given traditional care. In the knee group, 3,510 patients were given the decision tools, while 4,217 were given traditional care.
The patients were seen in an outpatient clinic during 18 months starting in January 2009 for the intervention group and during 18 months starting in January 2007 for the control group. Surgery rates were compared with rates of non Group Health patients in that region for each time period.
The fact that surgery trends were compared with those of the non Group Health patient community made it unlikely that the economic recession—which influenced fewer surgeries or cost savings—was responsible for the trend.
"We examined trends in hip and knee replacement in our region of Washington State (outside of Group Health) and found that the rates of hip and knee surgery were increasing or flat during the study period, not decreasing like we saw in our study," Arterburn says. "So that makes it much less likely that the economy was driving the change we saw in our system."
The report's authors qualified their findings. For starters, Group Health surgeons are all on salary, so volume of procedures does not influence their paychecks.
Second, it could not be determined whether the patients actually used the DVD or the online tool, or to what extent it may have influenced their decision.
Third, the followup period was six months, after which the patient may have gone ahead and had the surgery. "We cannot exclude the possibility that the decision aid implementation has only delayed the timing of joint replacement surgery," the authors wrote. "It is entirely possible, given the natural history of osteoarthritis, that patients who choose to forego joint replacement will reverse their decision later."
Fourth, Group Health providers have been during this study period moving to medical home payment models, and other initiatives are underway to make doctors and other clinicians aware of care costs and the importance of avoiding unnecessary procedures.
"Although osteoarthritis management was not a specific focus of the medical home initiative, it is possible that better primary care management of osteoarthritis may have contributed to observed declines in joint replacement," the researchers wrote.
Arterburn was asked if the decision tools might scare away patients who should legitimately have surgery. He says "Any patient who is 'scared away' from surgery by a decision aid that provides unbiased statistics about the likely probabilities of benefits and risks of surgery is a patient who prefers not to have surgery...they've seen the facts, and in their own best judgment, the facts don't personally add up to the surgery being a good decision for them at this time."
However, he says, "no decision should be made based on the facts presented in a decision aid alone. The decision aid is not a substitute for a conversation with their health care provider, who can use clinical judgment to advise the patient whether the probabilities presented in the video apply to patients like them."