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Increasing the use of patient decision aids in orthopaedic care: results of a quality improvement project
  1. Mahima Mangla1,
  2. Thomas D Cha2,3,
  3. Janet M Dorrwachter2,
  4. Andrew A Freiberg2,3,
  5. Lauren J Leavitt1,
  6. Harry E Rubash2,3,
  7. Leigh H Simmons1,3,
  8. Emily L Wendell1,
  9. Karen R Sepucha1,3
  1. 1 Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2 Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  3. 3 Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Karen R Sepucha, Division of General Internal Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA; ksepucha{at}


Objective To integrate patient decision aid (DA) delivery to promote shared decision-making and provide more patient-centred care within an orthopaedic surgery department for treatment of hip and knee osteoarthritis, lumbar herniated disc and lumbar spinal stenosis.

Methods Different strategies were used across three distinct phases to promote DA delivery. First, we used a quality improvement bonus to generate awareness and interest in the DAs among specialists. Second, we adapted the electronic referral management system to enable DA orders at referral to a specialist. Third, we engaged clinic staff and specialists to design workflows that promoted DA delivery. We tracked the number of patients who received a DA, who ordered the DA, and collected usage data from a subset of patients. Our target was to reach 60% of patients with DAs.

Results In phase 1, 28% (43/155) of spine patients and 37% (114/308) of hip/knee patients received a DA. In phase 2, 54% (64/118) of spine referrals and 58% (189/324) of hip/knee referrals included a request to send a patient a DA. In phase 3, 56% (90/162) of spine patients and 69% (213/307) of hip/knee patients received a DA, significantly more than in phase 1 (P<0.0001). In phase 3, both more DAs were ordered by clinic staff compared with specialists (56% phase 3 vs 34% phase 1, P<0.001) and sent before the visit (74% phase 3 vs 17% phase 1, P<0.001). Patients were more likely to report reviewing the DA when delivered before the visit (63% before vs 50% after, P=0.005).

Conclusion DA implementation into clinic workflow is possible and facilitated by engagement of the entire care team and the support of health information technology.

  • implementation science
  • quality improvement
  • shared decision-making
  • patient-centred care
  • surgery

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  • Handling editor Kaveh G Shojania

  • Contributors Each author has contributed significantly to, and is willing to take public responsibility for, one or more aspects of the study: TDC, AAF, HER, LHS and KRS participated integrally in the study design. All authors contributed to data acquisition as well as the analysis and interpretation of the study data. MM and KRS both drafted the initial manuscript; all other authors provided critical revisions and approved the final revisions.

  • Funding Gordon and Betty Moore Foundation (#3940)

  • Competing interests KRS reports grants from the Gordon and Betty Moore Foundation during the conduct of the study; other from Informed Medical Decision Foundation, outside the submitted work. TDC reports grants from the Gordon and Betty Moore Foundation during the conduct of the study; grants from North American Spine Society, personal fees from Bio2, personal fees from GE Healthcare, personal fees from Nuvasive, and personal fees from K2M outside the submitted work. HER reports personal fees from Stryker, personal fees from Ceramtec, personal fees from Lippincott, Williams & Wilkins, personal fees from Flexion Therapeutics, personal fees from Pacira, non-financial support from Hip Society, other from Orthopaedic Technology Group, outside the submitted work.

  • Ethics approval Partners Human Research Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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