Our review confirms the lack of published research on shared decision-making and patient decision aids in orthopaedic surgery, with no evidence about the use of patient decision aids for patients considering total joint replacement. All studies included in our review had been carried out in North America; given the differences in the organisation and provision of healthcare in the UK, their results may not be generalisable to the UK.
The single orthopaedic patient decision aid identified in the literature appears to increase knowledge and promote shared decision-making, and may decrease the uptake of surgery for back pain without affecting health outcomes. These observations have been confirmed by research in other specialties.7
However, caution is required in general-ising these results to other orthopaedic procedures.
Differences in gender, beliefs, and values appear to influence patients' decision making about joint replacement surgery. This evidence supports the argument that, in general, orthopaedic patients' knowledge and attitudes should be taken into account, and, in particular, patient decision aids should be designed to take these individual factors into consideration.
The main weakness of the review is the small number of studies identified. On the other hand, using a systematic search and appraisal strategy implies that this overview should represent a reasonable critical review of the available literature. There may be a bias towards research published in English as the search strategy excluded foreign language publications.
This is the first national survey of doctors in the UK regarding attitudes to patient decision aids. It has confirmed that orthopaedic surgeons are receptive to the use of patient decision aids as tools to support shared decision-making in their practice. This observation is compatible with studies of professional attitudes in North America.12,20,21
Survey respondents did not agree on all the suggested discussion topics. More than a third felt that discussion of clinical guidelines and financial costs should not be part of the consultation. One-fifth and one-quarter of respondents, respectively, felt that assessments of the patient's understanding of information and attitudes to risks/benefits need not be undertaken. Only 14% of respondents indicated it would be useful to discuss geographic variation in surgery rates, which suggests that this issue is not relevant to UK practice. Interestingly, when a topic was deemed appropriate for discussion, respondents were generally positive about the helpfulness of patient decision aids.
Responses about feasibility may have been influenced by an understanding of the patient group (i.e
. elderly patients) and a recognition of the limited resources available in the NHS. The majority favoured patient decision aids in booklet form, and favoured giving the patient the patient decision aid to take home. This preference for a booklet conflicts with current interest in exploring the use of patient decision aids on the Internet.22,23
Respondents acknowledged that elderly patients may not be comfortable with newer technologies, such as computers. Elderly patients may be more willing to assume a passive role in medical decisions.24
There were concerns about the impact of using patient decision aids in busy out-patient clinics. A number of respondents stated that they would be unlikely to use a patient decision aid if it made out-patient work more complicated. Other concerns about patient decision aids include: cost; the need for regular updates; the use of a generic package; and the possibility that not all patients would benefit. Similar concerns were articulated in a qualitative study performed in Canada,21
where clinicians worried about: complexity of patient decision aids, cost, availability, appropriateness of patient decision aids for certain groups of patients, and the time required to incorporate patient decision aids in patient consultations. Despite the generally positive attitudes to patient decision aids, there may be challenges to implementing a patient decision aid in routine orthopaedic clinical practice.
The main study limitation is the possibility of non-response bias, given our response rate of 57%. However, comparison of respondent and sampling frame summary characteristics showed similarities in terms of gender, age and length of time as a consultant.