Protocol for systematic review: patient decision aids for total hip and knee arthroplasty decision-making

Insights of shared decision-making and personalized treatment in orthopedics - A qualitative systematic review

Background

The shift from a paternalistic model to a patient-centered approach in medical decision-making has significantly transformed the doctor-patient relationship, especially in India. The rise of the Internet and patient education resources has empowered patients to actively participate in their healthcare decisions.

Methods

A systematic review was registered in PROSPERO [CRD420250652673] and was conducted using PubMed, Scopus, Web of Science (WoS), and Google Scholar, focusing on English-language publications about shared decision-making (SDM) in total joint replacement. Randomized controlled trials, studies on decision-making preferences, and disease-specific decision aids were included. Exclusion criteria encompassed advance directives and lifestyle-related decisions.

Results

SDM models have gained prominence globally, with various nations integrating patient rights and decision-making tools into their healthcare systems. Different patient care models, including paternalistic, informed, and SDM, have been critically examined for their advantages and limitations.

Conclusion

The review highlights the evolving nature of patient involvement in medical decisions, emphasizing the importance of SDM in aligning treatments with patient preferences and values.

Effectiveness of patient decision aids in patients with advanced kidney disease: a meta-analysis based on randomized controlled trials

PURPOSE

To systematically evaluate the decision effectiveness of patient decision aids (PtDAs) on the decision-making effect of patients with advanced chronic kidney disease.

METHOD

Two authors independently searched ten electronic databases [Web of science, PubMed, the Cochrane Library, Embase, CINAHL, EBSCO, CBM, CNKI, WanFang DATA and Vip database], to include randomized controlled trials of interventions through PtDAs in patients with advanced chronic kidney disease published from the inception of the database until April 2024. Two authors conducted a comprehensive quality evaluation (Cochrane 5.1.0) before independently extracting and analyzing the data with RevMan 5.2.

RESULTS

The study included 11 randomized controlled trials with a total of 1613 patients. According to the results, PtDAs can improve the decision knowledge [SMD = 0.53, 95% CI (0.26, 0.80), P = 0.0002] and decision preparation [SMD = 2.34, 95% CI (2.04, 2.65), P < 0.00001] of patients with advanced chronic kidney disease. Additionally, there was a substantial decrease in the levels of decision regret [SMD = - 1.33, 95% CI (- 2.11, - 0.55), P < 0.05] and decision conflict [SMD = - 0.88, 95% CI (- 1.47, - 0.28), P = 0.004].

CONCLUSION

The current available evidence indicates that PtDAs can significantly enhance the decision knowledge and decision preparation of patients with advanced chronic kidney disease. Additionally, PtDAs can reduce the levels of decision regret and decision conflict.

TRIAL REGISTRY

CRD42023433798.

The lifetime revision risk of primary anatomic and reverse total shoulder arthroplasty

BACKGROUND

Implant survival in total shoulder arthroplasty (TSA) is currently defined with reference to a set time period (eg, 5-year implant survival). This is a difficult concept for patients to understand, especially for younger patients who have more years of life remaining. Our study aims to calculate a patient's lifetime revision risk after primary anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty-a more meaningful projection of revision risk over a patient's remaining lifetime.

METHODS

The New Zealand Joint Registry (NZJR) and national death data was used to calculate the incidence of revision and mortality in all patients who underwent primary aTSA and rTSA in New Zealand between 1999 and 2021. Lifetime revision risk was calculated using previously described methods, and this risk was stratified by age (46-90 years, 5-year bins), sex, and procedure type (aTSA and rTSA).

RESULTS

In total, there were 4346 patients in the aTSA cohort and 7384 patients in the rTSA cohort. Lifetime revision risk was highest in the youngest age group (46-50 years) at 35.8% (95% CI 34.5%-37.0%) for aTSA and 30.9% (95% CI 29.9%-32.0%) for rTSA, with risk decreasing with increasing age. Across all age groups, the lifetime revision risk was higher for aTSA compared to rTSA. By sex, females reported higher lifetime revision risk for each age group in the aTSA cohort whereas males reported higher lifetime revision risk for each group in the rTSA cohort.

CONCLUSIONS

Our study demonstrates that younger patients have higher lifetime revision risk after total shoulder arthroplasty. Our results highlight the long-term revision risks associated with the trend of offering shoulder arthroplasty to younger patients. The data may be used among various health care stakeholders to inform the surgical decision-making process and plan for future health care resource use.

Adaptation and Implementation of a Shared Decision-Making Tool From One Health Context to Another: Partnership Approach Using Mixed Methods

BACKGROUND

Osteoarthritis is a leading cause of pain and disability. Knee osteoarthritis accounts for nearly four-fifths of the burden of osteoarthritis internationally, and 10% of adults in the United Kingdom have the condition. Shared decision-making (SDM) supports patients to make more informed choices about treatment and care while reducing inequities in access to treatment. We evaluated the experience of a team adapting an SDM tool for knee osteoarthritis and the tool's implementation potential within a local clinical commissioning group (CCG) area in southwest England. The tool aims to prepare patients and clinicians for SDM by providing evidence-based information about treatment options relevant to disease stage.

OBJECTIVE

This study aimed to explore the experiences of a team adapting an SDM tool from one health context to another and the implementation potential of the tool in the local CCG area.

METHODS

A partnership approach using mixed methods was used to respond to recruitment challenges and ensure that study aims could be addressed within time restrictions. A web-based survey was used to obtain clinicians' feedback on experiences of using the SDM tool. Qualitative interviews were conducted by telephone or video call with a sample of stakeholders involved in adapting and implementing the tool in the local CCG area. Survey findings were summarized as frequencies and percentages. Content analysis was conducted on qualitative data using framework analysis, and data were mapped directly to the Theoretical Domains Framework (TDF).

RESULTS

Overall, 23 clinicians completed the survey, including first-contact physiotherapists (11/23, 48%), physiotherapists (7/23, 30%), specialist physiotherapists (4/23, 17%), and a general practitioner (1/23, 4%). Eight stakeholders involved in commissioning, adapting, and implementing the SDM tool were interviewed. Participants described barriers and facilitators to the adaptation, implementation, and use of the tool. Barriers included a lack of organizational culture that supported and resourced SDM, lack of clinician buy-in and awareness of the tool, challenges with accessibility and usability, and lack of adaptation for underserved communities. Facilitators included the influence of clinical leaders' belief that SDM tools can improve patient outcomes and National Health Service resource use, clinicians' positive experiences of using the tool, and improving awareness of the tool. Themes were mapped to 13 of the 14 TDF domains. Usability issues were described, which did not map to the TDF domains.

CONCLUSIONS

This study highlights barriers and facilitators to adapting and implementing tools from one health context to another. We recommend that tools selected for adaptation should have a strong evidence base, including evidence of effectiveness and acceptability in the original context. Legal advice should be sought regarding intellectual property early in the project. Existing guidance for developing and adapting interventions should be used. Co-design methods should be applied to improve adapted tools' accessibility and acceptability.

Effectiveness of patient decision aids for total hip and knee arthroplasty decision-making: a systematic review

OBJECTIVES

To determine the effectiveness of patient decision aids (PtDAs) compared to alternative interventions (including usual care) on decision quality and quality of the decision-making process for adults with hip and knee osteoarthritis considering primary elective total joint arthroplasty.

METHODS

A systematic review guided by Cochrane methods and PRISMA reporting guidelines. Studies were searched in five databases. Included studies were RCTs evaluating the effect of PtDAs on total joint arthroplasty decision-making. Study quality was appraised with Cochrane's risk of bias tool. Quality and strength of recommendations were appraised with GRADE.

RESULTS

Ten included studies were conducted in North American using the same PtDA. Compared to usual care, PtDA groups demonstrated increased decision quality (e.g., higher knowledge, more informed values-based choices) and quality of the decision making process (e.g., decreased decisional conflict) (6 trials). Secondary outcomes showed increased surgeon satisfaction within the consultation and no difference in patient satisfaction or uptake of the chosen option (surgery: RR 1.03, 95% CI = 0.84 to 1.25; I² = 66%; 4 trials). When PtDAs formtats were compared, there were similar effects but no difference between PtDAs (4 trials).

CONCLUSIONS

There was low to very low GRADE certainty of evidence for the effect of PtDAs on decision quality and quality of the decision-making process compared to usual care. No differences were found when different formats of PtDAs were compared (moderate to very low GRADE certainty of evidence).