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“Surgery Is Certainly One Good Option”: Quality and Time-Efficiency of Informed Decision-Making in Surgery
Clarence BraddockIII, MD, MPH1; Pamela L. Hudak, BScPT, PhD2; Jacob J. Feldman, PhD3; Sylvia Bereknyei, MS1; Richard M. Frankel, PhD4; Wendy Levinson, MD, FRCPC5
1 Stanford University School of Medicine, 251 Campus Drive, MC 5475, Stanford, CA 94305-5475. E-mail address for C. Braddock III: cbrad@stanford.edu
2 Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
3 7500 Old Georgetown Road, Suite 620, Bethesda, MD 20814
4 Regenstrief Institute, 1050 Wishard Boulevard, Indianapolis, IN 46202
5 Department of Medicine, University of Toronto, 190 Elizabeth Street, Toronto, ON M5G 2C4, Canada
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institute on Aging, National Institutes of Health (R01 AG018781-05). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at Stanford University School of Medicine, Stanford, California, and University of Toronto, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Sep 01;90(9):1830-1838. doi: 10.2106/JBJS.G.00840
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Background: Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients.

Methods: We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought.

Results: There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons.

Conclusions: In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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