Commentary & Perspective by
Jeffrey N. Katz, MD, MS, John Wright, MD, and Elena Losina, PhD, MD*,
Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts
Patient Decision-Making and Total Joint Replacement
The benefits of total joint replacement are the most dramatic of any contemporary surgical procedures, yet fewer than 10% of patients who are appropriate candidates are willing to undergo this procedure1. Total joint replacement is especially underutilized in African American and Hispanic patients as well as in patients who have little or no income2. In this issue of The Journal, Clark et al. report a qualitative analysis of interviews with patients with lower-extremity arthritis who were deemed to be appropriate candidates for total hip or knee replacement but who were unwilling to consider having the joint replaced. The authors found that the decision to undergo total joint replacement reflects a dynamic balance, with the pain and disability imposed by lower-extremity arthritis on one side of the scale, and the perceived risks and costs of surgery on the other. The authors observed that the patients appeared to accommodate to pain and disability over time, which led to an upward shift in the threshold at which they would choose to undergo surgery.
The authors suggest that this threshold is highly individualized and is influenced by a person's perceptions of the burden of pain and disability as well as his or her evolving ability to cope with these burdens and garner social support. The authors contrast this subtle decisional balance with the rational, informed, utility-maximizing decision-maker of classic economic theory. They note that critics view decision and policy models that are based on classic theory as overly reductionistic and prescriptive.
This qualitative analysis of the decision-making process provides critical insight into the reasons that many patients refuse total joint replacement. We comment here on the substantive findings, their relevance to clinical care, and implications for research.
The principal finding—that patients obtain information on risks and benefits from health-care professionals and peers, weigh these risks and benefits, and rebalance them over time—is consistent with several theoretical models of decision-making3 that emphasize the balance between the perceived benefits and drawbacks of a behavior, the perceived barriers to moving forward, and the role of important persons who influence the decision-making of patients. The authors' observation that this balancing process is dynamic, with shifting thresholds over time, is an important finding that moves us forward in this field of knowledge.
We would add that perceptions of risk and benefit may be influenced by a wide range of factors, including literacy, educational attainment, income, race, and gender. The well-educated neighbor of an orthopaedic surgeon may feel entirely at ease with the prospect of a total knee replacement, whereas low-income, minority, or other vulnerable populations may view total joint replacement as beyond their horizon of possibility4. The primary-care provider is another key informant and advisor. Primary-care providers may overestimate the risks and underestimate the benefits of total joint replacement, thereby fueling underutilization.
This research has important implications in terms of improving the ways in which physicians communicate with patients with arthritis. Surgeons must appreciate the dynamic nature of decisional balance, and the importance of input from the primary-care provider, family, friends, and other valued advisors. The traditional discussion between surgeon and patient about whether to undertake joint replacement is typically done one-to-one, in a rushed office visit, with little time for questions and reflection. If we recognize, as Clark and colleagues suggest, that these decisions require ongoing reflection, reconsideration, and input from others, alternative models emerge to support the decision-making process.
First, several visits may be necessary before patients truly have processed the information regarding the risks and benefits of surgery and developed an awareness of their own preferences. Patients should be given an opportunity to speak with persons who have had surgery, with others who have deferred it, and with still others who are actively considering the operation. Discussions between physicians and patients regarding surgery could be conducted among groups of patients and could include family and friends. Formal sources of decisional support could also help patients with these choices5. Discussions between physicians and patients should be disease focused rather than procedure focused, encompassing the trajectory of arthritis progression with its attendant functional limitations, and evidence-based assessments of the risks and benefits of surgery and other options. Referring physicians should enter such discussions informed about the risks of complications, the likelihood of functional benefit and pain relief, the likely longevity of the implant, and the role of factors that may affect the short and long-term outcomes. In particular, referring physicians should be aware that patients whose functional limitation is advanced by the time of surgery may have worse outcomes than those who have surgery at an earlier point in the trajectory of functional decline6.
Finally, from a research standpoint, we agree that these findings help illustrate that the rational, informed decision-maker of classic economic theory is largely a theoretical construct. Our preferences, perceptions—and ultimately our decisions—are influenced by cultural, social, emotional, and other inputs. However, the role of policy models and cost-effectiveness analyses is not to prescribe individual decisions but rather to understand the results of current practices by quantitatively accounting for recognized outcomes and costs of health decisions. Modeling can anticipate decisions, even before all of the appropriate data are available, and can assist in optimal allocation of resources. In the end, each patient will make his or her own decision on the basis of a delicate weighing of perceived risks, benefits, and preferences. Models do not substitute for this nuanced process but rather serve to aggregate the effects of thousands of such decisions on the costs and benefits of a wide range of practices. This quantitative weighing of costs and benefits is critically needed in an era of increasingly limited resources.
*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
1. Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier
R, Wilkins A, Badley EM. Determining the need for hip and knee arthroplasty:
the role of clinical severity and patients' preferences. Med Care. 2001;39:206-16.
2. Escalante A, Barrett J, del Rincon I, Cornell JE, Phillips CB, Katz JN. Disparity in total hip replacement affecting Hispanic Medicare beneficiaries. Med Care. 2002;40:451-60.
3. Glanz K, Lewis FM, Rimer BK. Health behavior and health education: theory, research, and practice. 2nd ed. San Francisco: Jossey-Bass; 1997.
4. Katz JN. Patient preferences and health disparities. JAMA. 2001;286:1506-9.
5. Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG Jr. Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Med Care. 2000;38:959-69.
6. Fortin PR, Penrod JR, Clarke AE, St-Pierre Y, Joseph L, Belisle P, Liang MH, Ferland D, Phillips CB, Mahomed N, Tanzer M, Sledge C, Fossel AH, Katz JN. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 2002;46:3327-30.