Dr. John Richmond, chair of the orthopedics department at New England Baptist, said that as osteoarthritis progresses and cartilage at the knee joint disappears, it becomes increasingly difficult to prevent pain.
“To date we don’t really have a disease-modifying treatment that slows down the progression of osteoarthritis,” he said, so for many people a joint replacement is inevitable. But because artificial joints can wear out and need to be replaced over time, it’s a good idea for some people to take advantage of other treatments and put off a replacement as long as possible.
Ultimately, Richmond said, the choice comes down to a patient’s pain, their tolerance for pain, and the patient’s willingness to accept the risks of surgery.
Dr. David Arterburn, lead author of the Health Affairs study and a researcher at Group Health Research Institute in Seattle, calls the procedure “preference sensitive” because the choice to have one isn’t made solely on objective measures. That’s where decision aids come in. The goal, he said, is “to make sure that patients understand that there is more than one option when it comes to osteoarthritis treatment.”
Karen Sepucha, who directs the Health Decision Sciences Center at Massachusetts General Hospital, said that many medical decisions don’t have clear answers. “Whether or not you’re ‘clinically appropriate’ [for a procedure] doesn’t mean you should have it,” she said.
When doctors and patients are asked to list their goals and concerns about a procedure, “there’s very little overlap between what the doctors focus on and what the patients focus on,” she said.
To ensure that patients who choose major procedures truly want them, Mass. General now gives patients decision aids for 36 different conditions, including knee osteoarthritis. Even when decisions are straightforward, Sepucha said, the aids can help patients have more realistic expectations.
For David Wunsch, a 72-year-old retired professor of electrical engineering, the decision was clear. After a bicycle accident followed by knee surgery 12 years ago, Wunsch found that he had developed painful osteoarthritis. Physical therapy and steroid injections failed to help. Although he received a decision aid — a video — from his orthopedic surgeon at Mass. General, “I was in so much pain from this knee, I would have had a replacement whether or not I’d gotten the DVD,” he said. But he credits the video for helping him understand the magnitude of the procedure and the lengthy recovery. After his knee replacement, he can walk much more easily, and is working to improve his artificial knee’s range of motion so he can cycle again.
The explosion of knee replacements is forcing physicians to grapple with the questions of what the “right” rate is for the procedure, and whether all knee replacements are warranted. If well-informed patients choose knee replacements less often, as the Seattle study suggests, the answer to the second question seems to be “no.” And Arterburn believes the right rate for any procedure should be the rate resulting from educated patients, in which “the provider and the patient come to a shared agreement,” he said.
Courtney Humphries can be reached at email@example.com.