Thursday, August 18, 2011
Do Decision Aids in Spine Surgery Really Help?
Recently there has been a push to go through a shared decision making process with our patients considering various treatments for their spinal problems. One part of this process can be the decision aid, which frequently takes the form of an informational video that aims to provide patients with unbiased, evidence-based knowledge to help them make a more informed choice. In a recent paper based on data from the Spine Patient Outcomes Research Trial (SPORT), Dr. Lurie and his colleagues analyzed the effect of going through the shared decision making process, including watching an informational video, on treatment preferences. In addition, a small proportion of patients chose not to view the video and served as an observational control group. The authors found that the shared decision making process resulted in patients who had an initial preference for either surgery or non-operative treatment strengthening their preferences, with only 4% who had a baseline preference actually changing their preferred treatment. The major impact was on patients who were uncertain of their treatment choice at baseline - about half were able to identify a preferred treatment after the video – 27% choosing non-operative care and 22% surgery. Similar results were seen for disk herniation and spinal stenosis/degenerative spondylolisthesis patients. Compared to non-video watchers, those who saw the informational video were more likely to shift their preference.
While this study was not an RCT evaluating the effect of a decision-aid on treatment choice, it was a good observational study that demonstrated that decision aids do affect patients’ treatment preferences, either by allowing patients who are uncertain at baseline to identify an initial preference or by reinforcing the decision of those with a baseline preference. While some surgeons have been skeptical about the content of decision aids and have suggested that they might be biased towards non-operative treatment, the current investigation suggests that similar numbers of patients changed their preferences towards surgery or non-operative care. Other studies have evaluated the effect of informational videos on decision making in a randomized fashion, with some suggesting that it reduced the number of patients with disc herniation who chose surgery while slightly increasing the number with spinal stenosis opting for surgery. One difference between the prior RCT and the current study is that the prior study was done in a routine clinical practice setting without objective criteria for what constituted disc herniation or spinal stenosis while the current study was in the context of an RCT with clear inclusion and exclusion criteria. A future RCT comparing the effect of the decision aid on treatment selection in a group of highly-selected patients who meet the strict indications for surgery used in SPORT could be done to better define the role of this program in this population. It is not entirely clear, however, how useful additional studies would be. A recent Cochrane Collaboration Review identified more than 34 randomized trials evaluating decision aids for various conditions. In these trials, decision aids consistently improved knowledge, created more realistic expectations, reduced decisional conflict, and increased the proportion of patients who took an active role in decision making. Current evidence suggests that available decision-aids for patients with herniated discs and spinal stenosis contemplating surgery provide useful and balanced information for patients. The challenge will be how to motivate and facilitate providers to incorporate and improve tools to engage and involve patients in the decision making process. The current generation of decision aids offers patients probabilities of events and likely outcomes for the “average” patient. Since the “average” patient does not exist, future generations of decision aids will likely be able to predict outcomes accurately for specific individuals based on their unique characteristics.
Please read Dr. Lurie’s article and accompanying commentary. Will this article affect your shared decision making process? Leave a comment on The Spine Blog with your thoughts.
Adam Pearson, MD, MS
Jon Lurie, MD, MS
Dartmouth Medical School