Use of patient decision aids may lead to “sharply lower hip/knee surgery rates & costs”

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Photo credit: Cindy Funk via Flickr

A paper in Health Affairs (subscription required for access) shows what can be done with decision aids in clinical practice in what the authors describe as “the largest (observational study) to date of the implementation of patient decision aids in the context of quality improvement for elective surgery.”

A team from Group Health Cooperative in Seattle reports:

“Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions. However, little is known about how decision aids affect health care use when they are implemented outside of randomized controlled clinical trials. We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State. Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12–21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients’ and physicians’ preferences, may reduce rates of elective surgery and lower costs.”

Group Health says it has distributed more decision aids than any other single health care organization in the world. More than 25,000 Group Health patients have received decision aids, and is now distributing at the rate of about 900 more each month.

It should also be noted that 5 years ago, Washington passed the first state legislation recognizing the use of patient decision aids and “shared decision making” as a higher standard of informed consent.

The study was funded by the Commonwealth Fund. The implementation of decision aids was funded in part by the Informed Medical Decisions Foundation, which has been the sole supporter of this website for its entire existence.  However, no one at that Foundation influences what I publish on this site.  First author Dr. David Arterburn has also reviewed stories for

(Photo credit:  Cindy Funk via Flickr.  Creative Commons)


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September 4, 2012 at 4:11 pm

This is a great initiative, and extremely relevant for joint replacement surgery. A total hip or knee replacement tends to be one of those procedures that people do because their doctor suggests it. It isn’t always necessary. More importantly, there are a different types of hip and knee implants such as metal-on-metal, metal-on-plastic, etc. and each carries different risks. Patients should have this information before undergoing any type of procedure


September 4, 2012 at 7:27 pm

Wonder how many people just put off having the surgery for a few years. If you need a joint replacement, you need one and should have one. I put off having mine done for 5 years and feel incredibly better having recently had them done. Now I wish I hadn’t waited quite as long.

    Gary Schwitzer

    September 4, 2012 at 7:38 pm


    Thanks for your note and for sharing your experience. One of the main points of this research is that this is elective surgery. People are different. When informed about potential benefits AND potential harms, different people may choose differently. Different people may then define “need” differently.

    The researchers did acknowledge that “Although our findings are consistent with prior randomized trials, additional research is needed to confirm… whether introducing decision aids affects long-term arthritis symptoms and the need for repeat operations resulting from prosthesis failure.”

Greg Pawelski

September 5, 2012 at 11:50 am

The other side of the story: orthopedic device-related infections (ORDIs). Think Biofilm formation.

Both my parents, recipients of knee replacements, had to undergo the debilitating effects of post-surgical infections.

Because the percentage of patients aged >65 years is on the rise, the number of patients requiring implants continues to grow, as will the risk for ODRIs. In the United States, 4.4 million people have at least 1 internal fixation device and 1.3 million have an artifical joint.

Sophisticated prevention strategies have been developed during the past two decades to lower the risk of infectious complications in implant surgery. Although the incidence of ODRIs is low, even a low risk of infection can result in a number of patients with ODRIs. And the treatment of such an infection is poorly standardized.

In 2003, my mother experienced Biofilm formation to her knee device in her right leg. All implants undergo physiological changes after implantation. The earliest and probably clinically most important step is the “race for the surface,” a contest between tissue cell integration and bacterial adhesion to that same surface.

On contact, body fluids immediately coat all surfaces with a layer of host material, primarily serum proteins and platelets. Adherence progresses to aggregation of microorganisms on the surface of the foreign body, forming a Biofilm. Hers happen to be the deadly pseudomonas aeruginosa.

She had to have her device removed, debridgement, surrounding tissue cured of infection, and then a second prosthetic device implanted five months later. My father was luckier. He went right to antibiotic treatment, for the rest of his life, after an aspiration culture identified the bacterium. His life, however, circumbed to drug-induced pancreatitis, three years later.

My mother went on to fight another ODRI. This time, she lost her knee for good, with a little help of the nursing home she was at, not having “tippers” on her wheel chair, and falling out onto the floor (on her knees).