There has been a calling in the orthopedic literature to change the surgeon-patient encounter. Bryant et al
proposed and encouraged increasing communication between surgeons and patients to promote patient participation in decision-making. They suggested an increased use of decision aids in the clinical setting to facilitate the presentation of all available treatment options and their respective potential benefits and risks.25
Tools like the decision board have been tested extensively and found to be valid, reliable, and easy to use. Many studies have shown that decision boards improve patients’ knowledge as well as ability to participate in decision making.2,17,20,24
Increasing patients’ involvement in their care changes patient behavior and increases compliance with treatment.26,27
O’Connor et al
recently carried out a systematic review of 55 randomized controlled trials evaluating the efficacy of decision aids compared to no aid, usual care, or an alternative intervention. The review illustrated that patients who used a decision aid had greater knowledge and less decisional conflict due both to feeling uninformed and feeling unclear about personal values. Furthermore, decision aids reduced the proportion of patients who were passive in the decision-making process.28
Other studies also showed that patients in the decision board group were more satisfied with decision making following the consultation compared with patients in the conventional consultation group.16
This study demonstrates that this decision board is a valid and reliable tool to use for eliciting treatment preferences for displaced femoral neck fractures. The majority of participants found the decision board to be a highly acceptable method as it was easy to understand and enabled them to make an informed decision. Patients were also satisfied with the decision board as a method for presenting information, the amount of information presented to them, and using the decision board as a decision-making aid.
This decision board analysis also found that over half of the participants preferred IF relative to HA for the treatment of displaced femoral neck fractures. The main cited factors for this preference were less blood loss, shorter operative time, lower mortality, and less invasiveness. Although we ensured that participants were aware that reoperation for IF may mean having to undergo HA (or THA) with all its risks, most participants still thought that the previously mentioned factors outweigh the potential risks of reoperation.
However, it is important to note that the mean age of our participants was 44.1 years which is considerably younger than the targeted population (patients over 60 years old). Although a sub-analysis of the results showed that 55% of participants over the age of 60 years still preferred IF relative to HA, yet the preferences of our younger population may be different than preferences of patients above 60 years old. Furthermore, the material in our decision board was based on the data that was available from our literature review-up to January 2005. There have been a large number of recent studies that demonstrate different outcomes for the two treatment options (HA and IF). For example, the latest Cochrane review concluded that there was no difference in mortality rates between IF and HA.29
Furthermore, many newer studies have evaluated pain scores, functional outcomes, and quality of life improvements after IF or HA. These studies demonstrated a significant increase in functional outcome and quality of life scores for HA relative to IF.30,31
These factors are likely to influence patients preferences and choices and may change the conclusions of this part of the study. Therefore, it would be important to perform this decision board analysis with updated data and outcomes to patients above 60 years old to evaluate their preferred treatment option for displaced femoral neck fractures.
Nevertheless, this study displays that non-physicians’ preferences can be divergent from that of physicians and hence raise the possibility that patients’ preferences may also diverge from their physicians. Surgeons might underestimate patients’ preference for a less invasive surgery. Many studies have demonstrated the gap in the communication between patients and physicians when it comes to decision-making and choosing treatment options. For example, there is a significant difference between the thresholds of physicians and patients for the risk of excess bleeding deemed acceptable with antithrombotic therapy and the amount of reduction in risk of stroke thought necessary to justify warfarin treatment.32
Patients are willing to accept a much higher risk of bleeding for an associated reduction in risk of stroke compared to physicians. Furthermore, cancer patients are willing to accept intensive treatment with severe side effects for a much smaller chance of a benefit in terms of cure compared with doctors or nurses.33
There are several strengths to this study. We followed rigorous, well-defined methodology to develop and validate the decision aid. We used one-on-one interviews to ensure that all participants understood the questions being asked and provided their true preference. We demonstrated that the decision board is a valuable tool for inquiring about patients’ preferences and incorporating it into the decision-making process.
As mentioned, the sample of participants provides the main limitation to this study. Ideally, we would have involved real patients with femoral neck fractures at the point of decision making rather than relying on healthy members of society. However, at our institution and at most other centers, the decision to perform HA or IF in this patient population is at the discretion of the treating surgeon and most surgeons have strong opinions regarding the optimal treatment modality. Thus, we could not administer the decision board and elicit preferences in patients with femoral neck fractures since they would not be offered the two treatment options in practice. Testing the decision board in a clinical setting and eliciting actual patients’ preferences at the time of decision making is a research priority. In order to do this, a system would have to be set up whereby patients over the age of 60 years who suffer a displaced femoral neck fracture are asked about their preferred treatment option through the decision board with surgeons in that institution that are willing to offer the patient the option which they chose. However, since some surgeons may not be equally skilled in both techniques, the patient's choice may require moving to another surgeon.
Participants were given the option of choosing either IF or HA. A do-nothing alternative was not considered in this study because it is not an ethically acceptable option for displaced femoral neck fractures unless the patient has circumstances preventing operative treatment. Moreover, THA was not considered because until recently it was less commonly performed in this population and was reserved for patients with pre-existing osteoarthritis of the hip and it usually requires surgeons with specialty training which represent a small number of surgeons treating displaced femoral neck fractures.
In conclusion, this study demonstrates that our decision board effectively elicited preferences for the treatment of displaced femoral neck fractures and patients were highly satisfied and found the decision board acceptable as a decision making aid. With the debate regarding the surgical treatment of displaced femoral neck fractures unresolved and controversial, patients must become informed and involved in the decision making process. The decision board developed in this current study can help orthopedic surgeons.