Patients’ medical decisions benefit from DVD guidance

The use and testing of tools aimed at examining complex options is expanding across the country.

By Kevin B. O’Reilly — Posted Sept. 11, 2012

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An evidence-based video that reviews the pros and cons of back surgery to treat a herniated disk can help patients learn more about their condition and make medical decisions in line with their goals and preferences, said a study published Aug. 16 in Spine.

The 38-minute DVD was part of a tool known as a patient decision aid. These are videos, booklets and other materials designed to supplement face-to-face physician counseling on complex medical choices. The tools encourage patients to interpret the best available evidence in light of their care goals and often include stories from other patients to provide meaningful context about likely outcomes.

The Ottawa Hospital Research Institute lists nearly 300 English-language decision aids covering a wide variety of clinical areas, including allergies, depression and weight control. The tools promise to help time-squeezed physicians walk patients through tough choices while tapping unbiased and reliable sources of information as part of a process dubbed shared decision-making.

Yet evidence on how well decision aids improve patient knowledge and yield better decisions has lagged behind promotion of the tools.

For the study on back surgery decision-making, researchers compared 91 patients with herniated disks who received a decision aid with 92 patients who did not. On a 13-item test of patients’ knowledge about herniated disks, those who got the decision aid answered 55% of the questions correctly, compared with 38% for the patients who did not see the video, the study found (link).

The items covered essential questions about the condition, such as whether bed rest could help relieve the pain caused by a herniated disk. The evidence shows that bed rest does not help. Although 60% of the decision-aid patients knew that, only 51% of the other patients answered correctly.

“The goal with the knowledge questions is not to be tricky or pick out obscure facts,” said Karen R. Sepucha, PhD, the study’s lead author. “We need to do a better job of informing our patients.”Similar studies of how decision aids affect patients considering breast cancer surgery and coronary artery bypass graft surgery have yielded better results. Patient knowledge scores for those conditions have been in the 70%-to-90% range, said Sepucha, senior scientist with the Health Decision Sciences Center at Massachusetts General Hospital in Boston.

The herniated disk decision aid was created by the nonprofit Informed Medical Decisions Foundation, also in Boston. The foundation has been developing these kinds of materials since 1990, and is working to implement and test the tools with physicians and patients at 10 health care organizations around the country, including the Stillwater Medical Group in Minnesota and the University of California, San Francisco’s Breast Care Center.

Patient preferences are key

Massachusetts General is expanding its use of decision aids, said internist Creagh Milford, DO, a fellow in health policy and management at the Massachusetts General Physicians Organization, the medical group that serves the hospital. In September, the hospital is starting a pilot with cardiovascular care materials and will expand to orthopedic care in the fall.

The decision aids are part of a broader effort to avoid inappropriate procedures, an initiative that could mean shared savings for the hospital as part of the new pioneer accountable care organization. The plan is not to steer patients away from surgery, but to make sure their decisions are informed and well-deliberated, Dr. Milford said.

“The first phase is ensuring that every patient receives these shared decision-making materials,” said Dr. Milford, who also is an instructor of medicine at Harvard Medical School. “Even after patients have better education in some of these procedures, sometimes they choose to do the procedure, and in some cases they choose not to do it. It will be interesting to see which way the preferences go.”

With or without these decision aids, there are some ways doctors can help patients work through their options, according to the Informed Medical Decisions Foundation. These steps include:

  • Letting patients know that they have medical options and encouraging discussions about them.
  • Presenting choices with information on risks and benefits.
  • Helping patients assess options based on their care goals and concerns.
  • Asking patients what else they want or need to know before deciding.
  • Defining the next steps once a choice is made.

“We’re trying to figure out ways to help the doctors to shift their conversations, so it’s more about engaging with patients and less about just giving straight recommendations,” Sepucha said. “The patients have a huge role in this, too.”

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How decision aids inform patient choices

Patients who watched an evidence-based video to help them decide on treatment for a herniated disk scored 17 percentage points higher on a test of knowledge than patients who did not receive a decision aid. On questions covering topics such as surgical outcomes and medication risks, patients who got the decision aid reliably scored better.

Question (Correct response) Decision aid No decision aid
For most people with a herniated disk, how likely is it that doing normal activities will make their herniated disk worse? (Not very likely) 43% 27%
Over time, without surgery, does back and leg pain caused by a herniated disk usually get better, stay the same, or get worse? (Gets better) 53% 13%
Which treatment is most likely to provide faster relief from pain caused by a herniated disk? (Surgery) 53% 36%
Is excessive bleeding a possible side effect of using over-the-counter pain medicine for a long time? (Yes) 86% 67%

Source: “Psychometric evaluation of a decision quality instrument for treatment of lumbar herniated disc,” Spine, Aug. 15 (link)

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