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Spring 2011

Shared Decision Making for Joint Replacement

Choosing joint replacement surgery is the first in a series of difficult decisions for patients, who then must work with their physicians to decide on everything from the type of surgery and implant to their preferred pain and recovery strategies. As they do, patients are often inundated with advice from friends, family members, magazine ads, the Internet and more.

"It can get confusing," said Thomas Parker Vail, M.D., chief of Orthopaedic Surgery at UCSF Medical Center. "As surgeons, we have to find new ways to help patients wade through the complexity and make the best decisions for their needs."

A specialty center for joint replacement like UCSF is ideal for testing new methods of shared decision making because the combination of expert surgeons and advanced technology offers patients the full menu of joint replacement options.

Don’t We Already Do This?

Kevin Bozic, M.D., orthopaedic surgeon and researcher, said, "Most physicians think we already practice shared decision making, but too often there's a disconnect between the patient's and physician's views, especially when it comes to the risks, benefits and objectives of treatment alternatives."

He noted that while physicians have better knowledge of the patho-physiology, implants and surgical techniques, patients understand their lifestyle and postsurgical goals in ways that physicians don't always fully understand or integrate into their advice.

In an effort to improve the patient-physician dialogue, the UCSF joint replacement group will test adaptations of a shared decision-making methodology developed at the UCSF Carol Franc Buck Breast Care Center. "We want to create a set of practical tools for patients and surgeons to incorporate into their clinical decision making, so they emerge with an enhanced understanding of their values, preferences and treatment goals," Bozic said.

Randomized Study

The study will randomize patients to either usual care — speaking with a surgeon who reviews the alternatives, including nonoperative treatment — or shared decision making. The latter includes the following steps:

  • Before the appointment, patients are provided with decision aids in the form of a DVD and booklet.
  • After the patient reviews the decision aids, a health coach follows up to discuss and organize questions and concerns into a focused, written list.
  • The surgeon then reviews the list with the patient during his or her office visit.

"For other conditions, the literature shows that this process prepares patients better, creates a more efficient visit for time-constrained physicians and patients, and leaves both more satisfied with the encounter," Bozic said.

To ensure those results hold true for joint replacement, the UCSF team will carefully measure whether:

  • Patients enter their appointment better informed, have their decisional conflict eased and are satisfied with their decision long term.
  • Physicians are satisfied with the process.
  • Office visits are more efficient.

Personalized Medicine

"We talk a lot about over- and under-utilization, Bozic said. "We need to talk more about appropriate utilization. Having a dialogue around these decisions has the potential to improve the appropriateness of care."

Vail added, "Our goal is truly personalized medicine: finding the approach that delivers the best value for each individual patient."

Dr. Thomas Parker Vail can be contacted at (415) 502-5183.

Dr. Kevin Bozic can be contacted at (415) 353-2663.

Related Information

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