Implementation of a Decision Aid for Hip and Knee Osteoarthritis in Orthopedics: A Mixed-Methods Process Evaluation

Background. In orthopedics, the use of patient decision aids (ptDAs) is limited. With a mixed-method process evaluation, we investigated patient factors associated with accepting versus declining the use of the ptDA, patients' reasons for declining the ptDA, and clinicians' perceived barriers and facilitators for its use. Methods. Patients with an indication for joint replacement surgery (N = 153) completed questionnaires measuring demographics, physical functioning, quality of life (EQ-5D-3L), and a visual analog scale (VAS) pain score at 1 time point. Subsequently, their clinician offered them the relevant ptDA. Using a retrospective design, we compared patients who used the ptDA (59%) with patients who declined (41%) on all these measures as well as the chosen treatment. If the use of the ptDA was declined, patients' reasons were recorded by their clinician and analysed (n = 46). To evaluate the experiences of clinicians (n = 5), semistructured interviews were conducted and thematically analyzed. Clinicians who did not use the ptDA substantially (<10 times) were also interviewed (n = 3). Results. Compared with patients who used the ptDA, patients who declined use had higher VAS pain scores (7.2 v. 6.2, P < .001), reported significantly worse quality of life (on 4 of 6 EQ-5D-3L subscales), and were less likely to receive nonsurgical treatment (4% v. 28%, P < .001). Of the patients who declined to use the ptDA, 46% said they had enough information and felt ready to make a decision without the ptDA. The interviews revealed that clinicians considered the ptDAs most useful for newly diagnosed patients who had not received previous treatment. Conclusion. These results suggest that the uptake of a ptDA may be improved if it is introduced in the early disease stages of hip and knee osteoarthritis.