BMJ  2008;336:954-955 (26 April), doi:10.1136/bmj.39520.701748.94 (published 8 April 2008)

Making a Difference

Management of Chronic Pain

Improving shared decision making in osteoarthritis

¹ School of Nursing, University of Ottawa, Ottawa, Ontario, Canada, ² Division of Rheumatology, University of Toronto, Toronto, Ontario, ³ Department of Surgery, University of Ottawa, ⁴ Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center and Dartmouth Medical School, Lebanon, New Hampshire, USA, ⁵ Department of Medicine and Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, ⁶ Faculty of Medicine, University of Ottawa, ⁷ Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa

The burden of chronic pain for those who have it and their families is substantial, says Henry McQuay (doi: 10.1136/bmj.39520.699190.94), and these patients deserve better. Dawn Stacey and colleagues describe an example of quality improvement in practice for one group of people with chronic pain, those with osteoarthritis

Common treatments for osteoarthritis include physiotherapy, bracing, pharmacotherapy, and joint replacement surgery. When treatments are proposed that increase the risk of harm (such as non-steroidal anti-inflammatory drugs, opioids, or surgery), patients’ values concerning potential benefits and harms need to be considered. However, clinicians find it difficult to judge patients’ values, which are also often based on unrealistic expectations. Therefore tools that improve the shared decision making process are important.

Shared decision making is a process in which the patient and clinician together reach an informed decision about the plan of care on the basis of the patient’s clinical needs, priorities, and values. The clinician’s expertise lies in diagnosing and identifying treatment options according to clinical priorities; the patient’s role is to identify and communicate their informed values and personal priorities, as shaped by their social circumstances.

Patient decision aids are tools that prepare patients for consultations by explaining options, quantifying risks and benefits, helping patients to clarify their values, and providing structured guidance in deliberation and communication.¹ A review of 10 systematic reviews of patient decision aids found that they improved patients’ participation, increased their knowledge of treatment options, realigned their expectations, and improved the match between their values and subsequent treatment decisions.² The aids also reduced the overuse of elective surgery (for herniated disc, for example) without apparent adverse effects on health outcomes. Another study showed the potential for patient decision aids to reduce inequalities among ethnic groups.³ The Cochrane inventory of patient decision aids (www.ohri.ca/decisionaid) uses international standards to rate their quality.⁴ Decision aids for osteoarthritis treatment are available online, in brochures, and on DVD.

In 2006, patient decision aids were accessed more than eight million times, mostly through the internet.¹ Ideally, these tools should be linked to clinical care processes, but practitioners report several barriers to implementation: inappropriate content for their patients; forgetting to offer them; inadequate time; content that was too complex or too simple; and cost.⁵ Practitioners are more likely to use patient decision aids if they have a positive effect on patients’ outcomes or on the clinical interaction. Orthopaedic surgeons rated the content of patient decision aids for osteoarthritis treatments as good to excellent and were motivated to use them to improve patients’ understanding but had concerns about interrupting the flow of clinic work.⁶

Patient decision aids have been implemented successfully in specialist clinics in the United Kingdom⁷ and Canada and in specialist and primary care clinics in the United States.^{8 9} Patients with osteoarthritis, for example, use decision aids together with balanced, evidence based information on the treatment options and the likelihood of the benefits and harms of those treatments. The decision aids help patients clarify their values concerning benefits and harms by describing what it is like to experience them. Patients then complete a personal decision form, which elicits their knowledge, values, preferred option, and any unresolved "decisional needs" (for example, uncertainty about their preference, gaps in their knowledge of the options, lack of clarity of their values concerning benefits and harms, and support needs). This information is summarised on a "patient preference report," which is sent to the clinician to "close the loop" on decision making with the patient.

In Canada, patients on the waiting list for a surgical consultation are screened for eligibility by trained general practitioners or physiotherapists before they receive a decision aid and personal decision form. The Canadian patient preference report (figure 1) lists clinical priorities as determined by self reported pain and functional limitations, the trained screener’s assessment of surgical priority, and the patient’s preferences and decisional needs. The report is paper based, but one author (NC) has developed a similar computerised report as part of the US Veterans Administration’s electronic patient health records.

View larger version (27K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   An example of a patient preference report used in Canada

 
Using the patient preference report together with patient decision aids has the potential to improve the clinical encounter and to provide the incentive that practitioners need to overcome their resistance to using the aids. For example, when patients arrive at a surgeon’s consultation with their preference report, the surgeon can focus on issues of concern to the patient, such as fears of side effects of surgery. Thus the surgeon’s time will be used more efficiently, and the care provided is more patient centred, so patients and practitioners are both more likely to be satisfied with the process.

Outcomes such as pain reduction and improved function cannot be the sole quality indicators in treatments that involve trade-offs between potential benefits and harms. In such treatment decisions, the quality of decision making should be defined by how well the chosen treatment option matches the features that matter most to the informed patient.⁴ Patient preference reports document decision quality as an indicator of the shared decision making process. In addition to monitoring postoperative complications such as infections and blood clots, these reports can be used by quality improvement teams to monitor the extent to which high quality decisions are achieved and decisional needs met.¹⁰

Patient decision aids prepare patients for making shared decisions concerning treatment. Patient preference reports that summarise patients’ clinical and decisional needs improve communication. With standardised measures and documentation of decisions, healthcare organisations can monitor and include decision quality as another indicator of the quality of their programmes.

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Competing interests: All authors have received grants from the US Foundation for Informed Decision Making. The non-profit foundation has a licensing agreement with Health Dialog, a commercial company that markets patient decision aids and health coaching services.

Provenance and peer review: Commissioned; not externally reviewed.

References

1. O’Connor AM, Wennberg J, Legare F, Llewellyn-Thomas H, Moulton B, Sepucha K, et al. Towards the ‘tipping point’: decision aids and informed patient choice. Health Affairs 2007;26:716-25.[Abstract/Free Full Text]
2. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007;335:24-7.[Free Full Text]
3. Weng HH, Kaplan RM, Boscardin WJ, MacLean CH, Lee IY, Chen W, et al. Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum 2007;57:568-75.[CrossRef][Web of Science][Medline]
4. Elwyn G, O’Connor A, Stacey D, Volk R, Edwards A, Coulter A, et al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ 2006;333:417-22.[Abstract/Free Full Text]
5. Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions. BMC Implement Sci 2006;1:1-15.[CrossRef]
6. Llewellyn-Thomas HA, Weinstein J, Mimnaugh D. Patients’ decision aids for elective total joint replacement: a national survey to identify orthopaedic surgeons’ preferences. Med Decis Making 2003;23:551.
7. National Steering Group for Decision Support Aids in Urology. Implementing patient decision aids in urology—final report. 2005. www.pickereurope.org/Filestore/Research/Urology_steering_group_report.pdf.
8. Silvia KA, Sepucha KR. Decision aids in routine practice: lessons from the breast cancer initiative. Health Expect 2006;9:255-64.[CrossRef][Web of Science][Medline]
9. Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Affairs 2007;26:726-30.[Abstract/Free Full Text]
10. Dartmouth-Hitchcock Medical Center. Quality reports: knee replacement. 2008. www.dhmc.org/qualityreports/list.cfm?metrics=KR.

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