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2009 HSR&D National Meeting Abstract

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National Meeting 2009

3058 — Informed Decision-Making in the Orthopedic Setting Within the VA

Ling B (VA Pittsburgh), Hausman L (VA Pittsburgh), Mor M (VA Pittsburgh), Geng M (VA Pittsburgh), Ibrahim SA (VA Pittsburgh)

Objectives:
An informed decision-making approach has been proposed as a mechanism to improve quality of doctor-patient encounters and treatment decision-making. Such discussions are especially critical for preference-sensitive treatments, such as total joint replacement (JR) in the management of end-stage knee/hip osteoarthritis (OA). In a VA sample, we examined conversations between patients with OA and orthopedic specialists to determine the extent that they contained elements of informed decision-making (IDM), and whether IDM was associated with patient assessments of the encounter and surgical recommendation for JR.

Methods:
Audio-taped visits between patients and orthopedic surgeons discussing treatment options for knee/hip OA at Pittsburgh and Cleveland VA orthopedic clinics were coded using the IDM Model, which identifies nine decision-making domains of communication (e.g., alternatives, risks/benefits). Patients also rated the informativeness of their visit and ease of communicating with the surgeon. Whether JR was recommended was abstracted from medical records. The prevalence of each IDM domain was assessed, as was the frequency with which minimum criteria for informed decision-making (“IDM-min”) were met. We used chi-square tests to assess whether each IDM domain and IDM-min was associated with patient ratings of the encounter and JR recommendations.

Results:
Analyses included visits of 387 patients with 69 surgeons. We found high rates of most individual IDM domains, with five of the nine domains occuring in 80% or more of the visits (rates ranged from 24-89%) and IDM-min in 83%. Statistically significant (p < .05) positive associations were observed for patient ratings of informativeness and three IDM domains; patient ease of communication and five IDM domains plus IDM-min; and recommendation for JR and six IDM domains plus IDM-min. Of special note is that IDM-min occurred in 99% of visits in which recommendations for JR were made.

Implications:
IDM was highly prevalent in this sample of VA patient discussions with orthopedic specialists. Furthermore, the discussion of specific IDM elements was associated both with favorable patient ratings of the communication and treatment recommendation for JR.

Impacts:
Understanding the role of informed decision-making for patients considering preference-sensitive treatments, such as joint replacement, would help improve the quality of medical care and decision making.


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