Results Summary

What was the research about?

Osteoarthritis is a health problem that causes the cartilage in joints to wear away. People may have painful or stiff joints and find it hard to move. Some people choose joint replacement surgery to relieve pain and stiffness. But the surgery has risks, such as infection or nerve damage.

In this study, the research team compared two decision aids to help patients decide if they want surgery for knee or hip osteoarthritis. Decision aids help people choose between two or more healthcare options based on what’s most important to them. One group of patients used a long decision aid with a 45-minute DVD and a 40-page booklet. The other group used a short decision aid with an interactive website and a 17-page pamphlet. The team also wanted to learn if sharing a report on a patient’s preferences with their surgeon improved decision making.

What were the results?

The two decision aid groups didn’t differ in the

  • Rate of patients who reported making an informed decision about surgery
  • Number of patients whose treatment matched their preferences
  • Rate of patients who had surgery

Patients who received the short decision aid had more knowledge about different treatment options than patients who received the long decision aid.

Sharing the report with surgeons didn’t improve decision making more than the decisions aids alone.

Who was in the study?

The study included 1,124 patients ages 21 and older who were considering surgery for knee or hip osteoarthritis. Of these patients, 91 percent were white and non-Hispanic; 11 percent were other races or ethnicities. The average age was 65, and 57 percent were women.

What did the research team do?

The research team assigned patients by chance to receive the short or long decision aid. Patients reviewed the aids before they visited their doctor to talk about surgery. The team also assigned patients’ surgeons by chance to receive the patient preference report or not. The one-page report included patients’ goals for the visit and their treatment preferences. It also had the impact of the condition on their daily life.

Patients completed three surveys during the study. One survey took place before the visit and the second survey took place one week after. The final survey was six months after the visit or six months after surgery if patients chose surgery.

Patients with knee or hip osteoarthritis, surgeons, and staff from health plans and health systems gave input on the study.

What were the limits of the study?

Only a small number of surgeons used the patient report, making it hard to study the effect of the report. Most patients in the study were white and non-Hispanic. Results may differ for patients of other races and ethnicities.

Future research could continue to look at the best ways to include patient preferences in decisions about surgery.

How can people use the results?

Surgeons can use the results when considering ways to help patients decide on surgery for knee or hip osteoarthritis.

Final Research Report

View this project's final research report.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers questioned the odds ratios of several outcomes that were based on whether or not patients were able to make informed, patient-centered (IPC) decisions using the patient decision aids used in this study. The reviewers noted that the odds for surgery, and for less hip pain and knee pain seemed unusually high for the IPC group versus the non-IPC group, and suggested that there was an unaccounted-for bias in the analyses. The researchers refuted the claim of bias but acknowledged that risk ratios would be more appropriate measures for these outcomes than odds ratios. The researchers changed the results in the report to provide the risks of surgery, hip pain, and knee pain related to IPC decisions rather than the odds of these outcomes.
  • The reviewers raised questions about the use of an existing patient advisory committee, whose members appeared to have varying levels of experience with orthopedic conditions. The reviewers also questioned how engaged the patient advisors were in various aspects of the research study. The researchers said the patient advisory committee had been created by their institution specifically to support the development of patient decision aids for orthopedic research. The patient advisors they worked with all had experience with orthopedic conditions, either osteoarthritis or low back pain, and were involved in developing the research proposal, designing aspects of the project, selecting outcomes, supporting patient recruitment efforts, and interpreting the data. The researchers added that they invited the patient advocates to participate as authors on publications but the patient advocates asked to be acknowledged instead after reviewing authorship requirements for peer-reviewed reports.
  • The reviewers had questions about the study’s primary outcome, which was the proportion of IPC decisions. The researchers explained that the IPC measure was a composite measure of two key elements that patient advocates had emphasized: whether patients are informed and whether they receive their preferred treatment. The study found a lack of concordance between these two elements in some patients, and the researchers said they plan to explore the reasons for this discordance in future studies.
  • The reviewers challenged the researchers’ statement advocating the use of either of the two tested patient decision aids, since there was no evidence in this study that either decision aid produced better outcomes than usual care. The researchers responded that while their study did not include a usual care arm, past studies show that patients in usual care had about half the level of IPC decision-making levels as observed in this study. The researchers agreed that including a usual care arm would be helpful in future, similar studies.

Conflict of Interest Disclosures

Project Information

Karen Sepucha, PhD
Massachusetts General Hospital
$1,697,901
10.25302/02.2021.CDR.150328799
Comparative Effectiveness of Decision Support Strategies for Joint Replacement Surgery

Key Dates

September 2015
November 2020
2015
2020

Study Registration Information

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Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
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Last updated: January 20, 2023