Increasing the use of patient decision aids in orthopaedic care: results of a quality improvement project

BMJ Qual Saf. 2018 May;27(5):347-354. doi: 10.1136/bmjqs-2017-007019. Epub 2017 Nov 24.


Objective: To integrate patient decision aid (DA) delivery to promote shared decision-making and provide more patient-centred care within an orthopaedic surgery department for treatment of hip and knee osteoarthritis, lumbar herniated disc and lumbar spinal stenosis.

Methods: Different strategies were used across three distinct phases to promote DA delivery. First, we used a quality improvement bonus to generate awareness and interest in the DAs among specialists. Second, we adapted the electronic referral management system to enable DA orders at referral to a specialist. Third, we engaged clinic staff and specialists to design workflows that promoted DA delivery. We tracked the number of patients who received a DA, who ordered the DA, and collected usage data from a subset of patients. Our target was to reach 60% of patients with DAs.

Results: In phase 1, 28% (43/155) of spine patients and 37% (114/308) of hip/knee patients received a DA. In phase 2, 54% (64/118) of spine referrals and 58% (189/324) of hip/knee referrals included a request to send a patient a DA. In phase 3, 56% (90/162) of spine patients and 69% (213/307) of hip/knee patients received a DA, significantly more than in phase 1 (P<0.0001). In phase 3, both more DAs were ordered by clinic staff compared with specialists (56% phase 3 vs 34% phase 1, P<0.001) and sent before the visit (74% phase 3 vs 17% phase 1, P<0.001). Patients were more likely to report reviewing the DA when delivered before the visit (63% before vs 50% after, P=0.005).

Conclusion: DA implementation into clinic workflow is possible and facilitated by engagement of the entire care team and the support of health information technology.

Keywords: implementation science; patient-centred care; quality improvement; shared decision-making; surgery.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Academic Medical Centers
  • Aged
  • Decision Making
  • Decision Support Techniques*
  • Electronic Health Records / organization & administration
  • Female
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Intervertebral Disc Displacement / surgery
  • Male
  • Middle Aged
  • Orthopedics / organization & administration*
  • Osteoarthritis / surgery
  • Patient Care Team
  • Patient Participation / methods*
  • Quality Improvement / organization & administration*
  • Referral and Consultation / organization & administration
  • Socioeconomic Factors
  • Spinal Stenosis / surgery
  • Workflow