Decision Aid for Patients Considering TKA
Decision Aid for Patients Considering TKA
Of the180 patients deemed appropriate for surgical consultation between February 2007 and April 2008, 142 (78.9%) were eligible and consented to participate (see Figure 2). The most common reason for ineligibility was inadequate English. Of those eligible, 71 were randomized to the PtDA intervention group, 71 to usual education group. Sixty-six patients in both groups (93%) completed the questionnaires after exposure to the PtDA intervention and/or usual education materials. For those who completed the questionnaires, there was less than 1% missing responses for individual items. Two participants from the PtDA intervention group withdrew from the study and three participants from the usual education group were lost to follow-up. When supplemented with data from the hospital health information system, data on 140 (98.6%) patients was used for analysis of wait times.
(Enlarge Image)
Figure 2.
CONSORT trial flow diagram.
Patient demographic characteristics indicate that the typical participant was 67 years of age, female, retired, and had completed secondary school (see Table 1). There were no statistically significant baseline differences between the groups based on demographic characteristics, WOMAC scores, or HKPT scores.
Overall, patients' feedback about the PtDA was positive. Patients liked using the PtDA as a tool to communicate and share with others. Patient 40 said that the PtDA "…helped my spouse to understand what I was going through". Comments indicated that patients liked the presentation and some said it helped them arrive at a decision. For instance, Patient 101 reported, "…the information regarding total knee replacement was very good" and Patient 97 indicated, "This material was very helpful. It helped me to decide that of all the options available, knee replacement surgery is the best option in my case." Patients said the PtDA helped them learn the facts and have their questions answered. For example, Patient 117 said "…the video clarified the points that I had questions on" and Patient 96 highlighted, "I have investigated this to death and found the tape very good." Finally, the PtDA helped patients understand that they had a role in decision making, which was supported by Patient 126's comment, "Excellent tool that really helped me understand the importance of my collaborative decision making with the health care team."
Ten patients provided negative feedback. Some wanted more information about "…the wait time, the recovery time, and the consequences" (Patient 98). Information that was described as confusing included when "people were talking about personal stories" (Patient 21), and "pictures on the first page" (Patient 24).
At the end of the 1-year follow-up period (May 2009), 55 of 69 patients in the PtDA group had undergone surgery (79.7%; 95% CI 70.2 to 89.2%), 5 chose non-surgical management, 8 were still on the waiting list for surgery, and 1 had died. Of 68 patients in the usual education group, 48 underwent surgery (70.6%; 95% CI 59.8 to 81.4%), 9 chose non-surgical management, 10 were still on the waiting list for surgery, and 1 had died. There was no statistically significant difference between groups in the proportions of patients undergoing surgery (difference between PtDA versus usual education 9.1%, 95% CI -5.3% to 23.5%, p = 0.2165).
The median total wait times from the screening consultation to a definitive decision (e.g. underwent surgery or off wait list for non-surgical management) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) compared to 33.0 weeks for the usual education group (n = 71, 95% CI: 26.1, 39.9) (see Figure 3). There was no significant difference in the time on the wait list between groups (log-rank p = 0.6622).
(Enlarge Image)
Figure 3.
Wait times (screening to definitive decision) by group.
Mean knowledge scores for patients who used the PtDA were 71.2% compared to 46.6% in the usual education group (p < 0.01) (see Table 2). Patients in the PtDA group were more likely to have a higher quality decision (informed choice that matched their values for outcomes of options) (31 of 55 (56.4%) versus 14 of 56 (25.0%); p < 0.001). After exposure to the intervention and prior to the surgeon consultation, 20 of 66 patients in the PtDA group (30.3%) were unsure of the best option (prefer surgery or prefer non-surgery) compared to 9 of 66 patients in the usual education group (13.6%) (p = 0.0208). There were no statistically significant differences between groups for any items on the Decisional Conflict Scale or Preparation for Decision Making scale.
Results
Feasibility
Of the180 patients deemed appropriate for surgical consultation between February 2007 and April 2008, 142 (78.9%) were eligible and consented to participate (see Figure 2). The most common reason for ineligibility was inadequate English. Of those eligible, 71 were randomized to the PtDA intervention group, 71 to usual education group. Sixty-six patients in both groups (93%) completed the questionnaires after exposure to the PtDA intervention and/or usual education materials. For those who completed the questionnaires, there was less than 1% missing responses for individual items. Two participants from the PtDA intervention group withdrew from the study and three participants from the usual education group were lost to follow-up. When supplemented with data from the hospital health information system, data on 140 (98.6%) patients was used for analysis of wait times.
(Enlarge Image)
Figure 2.
CONSORT trial flow diagram.
Patient demographic characteristics indicate that the typical participant was 67 years of age, female, retired, and had completed secondary school (see Table 1). There were no statistically significant baseline differences between the groups based on demographic characteristics, WOMAC scores, or HKPT scores.
Overall, patients' feedback about the PtDA was positive. Patients liked using the PtDA as a tool to communicate and share with others. Patient 40 said that the PtDA "…helped my spouse to understand what I was going through". Comments indicated that patients liked the presentation and some said it helped them arrive at a decision. For instance, Patient 101 reported, "…the information regarding total knee replacement was very good" and Patient 97 indicated, "This material was very helpful. It helped me to decide that of all the options available, knee replacement surgery is the best option in my case." Patients said the PtDA helped them learn the facts and have their questions answered. For example, Patient 117 said "…the video clarified the points that I had questions on" and Patient 96 highlighted, "I have investigated this to death and found the tape very good." Finally, the PtDA helped patients understand that they had a role in decision making, which was supported by Patient 126's comment, "Excellent tool that really helped me understand the importance of my collaborative decision making with the health care team."
Ten patients provided negative feedback. Some wanted more information about "…the wait time, the recovery time, and the consequences" (Patient 98). Information that was described as confusing included when "people were talking about personal stories" (Patient 21), and "pictures on the first page" (Patient 24).
At the end of the 1-year follow-up period (May 2009), 55 of 69 patients in the PtDA group had undergone surgery (79.7%; 95% CI 70.2 to 89.2%), 5 chose non-surgical management, 8 were still on the waiting list for surgery, and 1 had died. Of 68 patients in the usual education group, 48 underwent surgery (70.6%; 95% CI 59.8 to 81.4%), 9 chose non-surgical management, 10 were still on the waiting list for surgery, and 1 had died. There was no statistically significant difference between groups in the proportions of patients undergoing surgery (difference between PtDA versus usual education 9.1%, 95% CI -5.3% to 23.5%, p = 0.2165).
Preliminary Effectiveness Outcomes
The median total wait times from the screening consultation to a definitive decision (e.g. underwent surgery or off wait list for non-surgical management) was 33.4 weeks for the PtDA group (n = 69, 95% CI: 26.0, 41.4) compared to 33.0 weeks for the usual education group (n = 71, 95% CI: 26.1, 39.9) (see Figure 3). There was no significant difference in the time on the wait list between groups (log-rank p = 0.6622).
(Enlarge Image)
Figure 3.
Wait times (screening to definitive decision) by group.
Mean knowledge scores for patients who used the PtDA were 71.2% compared to 46.6% in the usual education group (p < 0.01) (see Table 2). Patients in the PtDA group were more likely to have a higher quality decision (informed choice that matched their values for outcomes of options) (31 of 55 (56.4%) versus 14 of 56 (25.0%); p < 0.001). After exposure to the intervention and prior to the surgeon consultation, 20 of 66 patients in the PtDA group (30.3%) were unsure of the best option (prefer surgery or prefer non-surgery) compared to 9 of 66 patients in the usual education group (13.6%) (p = 0.0208). There were no statistically significant differences between groups for any items on the Decisional Conflict Scale or Preparation for Decision Making scale.
