Purpose: The purpose of the pilot study is to evaluate the effectiveness of a shared decision-making conversation using a personalized tool on lifestyle modifications on physical activity and knee pain.
Background: Shared decision-making (SDM) is a key component of patient-centered care where clinical evidence and the patient’s preference and values are considered. Disparities in osteoarthritis (OA) treatment are costly and the utilization of treatment across sex and race are well documented. Delaying treatment for OA-related knee pain imposes an increased cost in all groups and decreased benefit. Physical activity (PA) and weight loss are often the recommendations in the treatment plan, especially in mild to moderate stage of OA. Movement is Life (MIL) created an innovative SDM tool to provide a framework for patient centered discussions guiding a patient from contemplation to action. Nurses, specifically care coordinators and navigators, have opportunities to provide a SDM conversation when the patient presents with knee pain. The MIL tool leverages an underlying Markov model and represent the likely pain, activity levels, and lost productivity at three future time points. By comparing the patient’s likely progression based on treatment choices compared to doing nothing, the patient has an illustration of their future state.
Methods: A pilot study using a quantitative design of N=108 women, aged 45- 64, with chronic knee pain for at least three months and at least one co-morbidity (obesity, hypertension, and diabetes) were randomized to a control (n=54) or intervention (n=54) are of the study at eight centers across the U.S. Patient biodemographic data (age, gender, race/ethnicity, self-report levels of pain and activity levels, history of comorbid conditions, education level, and payer information) and two treatment paths appropriate to the patient’s knee condition are used as inputs in the tool. Eight pathway options ranging from PA, weight loss, and OTC medication to two pathways adding knee arthroplasty at two- and four-year projection. The intervention of a shared decision-making conversation used a visual output providing an illustration of the likely outcomes of the treatments selected on the level of knee pain, function, and the financial productivity of the patient over the next one, three, and six years. The tool compared these treatments to “doing nothing,” highlighting the impact of non-adherence.
Results: Results showed the demographics were similar between groups. At one month, n=47 control and n=50 intervention patients returned for evaluation. Self-reported level of PA increased in the intervention group (56% vs. 34%, p=0.0229). Qualitative feedback from the intervention group indicated high satisfaction with use of the tool.
Implications: The quasi scrips provides a communication plan which may reduce disparities by addressing unconscious bias in treatment decisions. Unmanaged knee pain and the delay in SDM conversations on treatment may lead to "cherry picking" healthier populations for surgical care and miss opportunities to provide the patient information on their future state impacting outcomes.
Evidence-based references
1. Johnson, C.(2021). A Personalized Shared Decision-Making Tool for Osteoarthritis Management of the Knee. Publication 2021 MS.NO. ONJ1561R1 Publication: Orthopaedic Nursing Journal.
2. Arthritis Care Res (2018) Nov;70(11):1569-1575. Intentional Weight Loss in Overweight and Obese Patients with Knee Osteoarthritis: Is More Better? doi: 10.1002/acr.23608.
3. Bruner, E. (2020). Social determinants of health: The zip code is the most important number on the patient’s chart! Virginia Nurses Today, 28(1), 12–13.
4. Gaskin, et al. (2018). The potential role of cost and quality of life in treatment decision for arthritis –related knee pain for African American and Latina women. doi:10.1002/acr.23903
5. Heath, S. (2018). Why value-based care must include shared-decision making. Retrieved from: https://patientengagementhit.com/news/why-value-based-care-must-include-shared-decision-making
6. Karmarkar, et al., (2017). A fresh perspective on a familiar problem: Examining disparities in knew osteoarthritis using a Markov model. Medical Care, 0 (0), 1-8.