Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty

Current treatments for knee osteoarthritis (OA) alleviate symptoms, but do not affect disease progression. For patients with pain and disability unresponsive to medical treatment, total knee arthroplasty (TKA) results in substantial pain relief and functional improvement.1 In 2006, the rate of TKA in the US was more than double that of the previous decade,2 and is expected to continue to rise with advanced aging of the population.3 Despite its benefits, TKA is not without risks. Perioperative complications can occur, and furthermore, prosthesis failure may require surgical revision. Because TKA is an elective procedure and patients must carefully weigh potential benefits and risks, the decision-making process is complex and uncertainty is common. Decisions are strongly related to patients' pre-existing preferences and values and the patient-physician relationship.4,5 Furthermore, some groups such as African Americans and older patients are less likely to choose surgery over conservative therapy.6-10 Qualitative research has demonstrated that patients' misperceptions of surgery in general, misunderstanding of the etiology of OA and its progressive nature, low expectations of TKA outcomes and fear of surgical complications all influence patients' preferences for this procedure. 5,11-13 Clear communication between the patient and physician leading to mutual understanding of the risks and benefits of treatment options for OA increase patient confidence and may lead to higher satisfaction with decision.13 However, the clinical encounter is usually short, and often there is not sufficient time to discuss in-depth the complex issues that patients must understand to clarify their values and make a decision. Patient decision aids can reduce the level of uncertainty or ‘decisional conflict’.14 These tools increase patients' knowledge about the risks and benefits of therapeutic alternatives, help them clarify their values and preferences, and prepare them for the encounter with their physician and deciding on a course of action.14,15 Conjoint analysis has been used for over a decade to explore patient preferences in healthcare.16 This approach enables patients to evaluate tradeoffs between two or more scenarios which present different levels of attributes (risks and benefits) related to the health or therapeutic problem presented to them. Adaptive conjoint analysis (ACA) is a specific type of conjoint analysis that has been explored extensively by Fraenkel et al. to describe patient preferences and values impacting decision-making in rheumatic conditions.17-19 ACA collects and analyzes preference data using an interactive computer program (Sawtooth Software ®). ACA is unique in that it uses an individual respondent's answers to update and refine questions through a series of paired-comparisons (see Figure 1). In addition, because it forces respondents to cognitively engage in the choice between alternatives with competing risks and benefits, it is considered a values clarification exercise of the various attributes pertinent to the decision. The assumption is that the interactive exercise provides the patient with a “deeper insight into his or her own constellation of decision-relevant values.”20 Figure 1 CONSORT diagram of participants We conducted a prospective, three arm randomized controlled trial (RCT) to compare ACA coupled with a videobooklet patient decision aid to the videbooklet alone and to standard educational materials regarding patients' decisional conflict associated with TKA for knee OA.