協助黑人患者增加膝關節置換的決定輔助


  【24drs.com】根據一篇多中心隨機研究,相較於典型的教育手冊,輔助決定之影片顯著增加了膝蓋骨關節炎(knee osteoarthritis,OA)黑人患者進行全膝關節置換(total knee replacement,TKR)手術的百分比達85%;這影片也使接受骨外科醫師之TKR建議者增加達接近三分之一,不過,這項關聯未達統計上的顯著意義。
  
  研究者寫道,以患者為中心的教育工具,如決定輔助,可幫助降低獲得偏好敏感性手術治療如全膝關節置換術的種族差異。
  
  賓州健康權益研究暨促進中心、費城退伍軍人事務醫學中心、賓州大學Perelman醫學院醫學系、一般內科Said A. Ibrahim醫師等人在11月20日的JAMA Surgery期刊線上發表他們的結果。
  
  在美國,骨關節炎是失能的主要原因,黑人成人的盛行率和白人成人一樣高,不過,之前的研究顯示,儘管TKR有其效益,黑人進行TKR的比率顯著低於白人同齡者。
  
  為了降低此項差異,Ibrahim醫師等人納入336名50歲以上、患有慢性頻發膝蓋疼痛的黑人患者,納入基準是依據全國健康與營養檢視調查問卷(National Health and Nutrition Examination Survey questionnaire)、西安大略麥克馬斯特大學骨關節炎分數達39分以上且有放射線證據顯示膝蓋OA。
  
  這篇研究排除了曾有主要關節置換、末期疾病、醫師診斷為發炎性關節炎、腿部義肢、認知障礙、缺乏家庭電話服務、或對選擇性置換手術有禁忌症的患者。
  
  隨機指派患者到介入組(n = 168人),觀看40分鐘的TKR手術利弊解說影片,或者是指派到對照組(n = 168人),接受標準的教育手冊。這項研究的主要結果是,在介入的12個月內接受TKR手術和/或在介入的6個月內接受骨外科醫師的TKR手術建議。
  
  在治療意向(ITT)分析中,對照組有7.7%(n = 13/168)、介入組有14.9% (n = 25/168)的患者在介入後12個月內進行手術。在符合方案分析中,對照組與介入組分別有7.1% (n = 11/154)與15.3% (n = 23/150)的患者在介入後12個月內進行手術(P = .02)。
  
  在ITT分析中,對照組有15.5% (n = 26)、介入組有20.2% (n = 34)的患者在6個月內接受手術建議(P = .25),不過,在符合方案分析中,對照組(15.6%;n = 24/154)與介入組(20.7%;n = 31/150)的接受手術建議比率並無顯著差異,校正研究地點之後,結果相似。
  
  作者們寫道,決定輔助提供關於治療選擇的高品質資訊,同時還釐清治療選擇的結果。透過這種方式,他們授權患者並促進溝通和決定。決定輔助隨著患者的知識而增加,患者對於疾病或治療的看法更切實、更少的決策衝突、更少的被動決定型患者、更少的諮詢後仍然不決定的患者,並改善患者價值和治療選項之間的一致性。
  
  資料來源:http://www.24drs.com/
  
  Native link:Decision Aid Increases Knee Replacements Among Black Patients

Decision Aid Increases Knee Replacements Among Black Patients

By Troy Brown, RN
Medscape Medical News

A video decision aid significantly increased the percentage of black patients with knee osteoarthritis (OA) who underwent total knee replacement (TKR) by 85% compared with a typical educational pamphlet, according to a new randomized, multicenter study.

The video also increased the likelihood of receiving a recommendation for TKR from an orthopedic surgeon by almost a third, but this association was not statistically significant.

"Patient-centered educational tools such as decision aids might help reduce racial disparities in access to preference-sensitive surgical treatments such as total knee replacement," the researchers write.

Said A. Ibrahim, MD, MPH, from the Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, both in Philadelphia, Pennsylvania, and colleagues published their findings online November 23 in JAMA Surgery.

Osteoarthritis is a leading cause of disability in the United States, with a prevalence among black adults at least as high as that among white adults. However, previous studies have shown that black patients undergo TKR at a significantly lower rate than their white peers, despite its demonstrated benefits.

To try to reduce the dispartity, Dr Ibrahim and colleagues enrolled 336 black patients aged 50 years or older with chronic, frequent knee pain on the basis of the National Health and Nutrition Examination Survey questionnaire, a Western Ontario McMasters University Osteoarthritis score of 39 or higher, and radiographic evidence of knee OA.

The study excluded patients with prior major joint replacement, terminal illness, physician-diagnosed inflammatory arthritis, prosthetic leg, cognitive impairment, lack of home telephone service, or contraindications to elective replacement surgery.

Patients were randomly assigned to the intervention group (n = 168), which included viewing a 40-minute video describing the risks and benefits of TKR surgery, or a a control group (n = 168), which included receiving a standard educational brochure. The study's main outcomes were receipt of TKR surgery within 12 months of the intervention and/or TKR surgery recommendation from an orthopedic surgeon within 6 months after the intervention.

In the intention-to-treat (ITT) analysis, 7.7% (n = 13 of 168 patients) in the control group and 14.9% (n = 25 of 168 patients) in the intervention group underwent surgery within 12 months of the intervention. In the per-protocol analysis, 7.1% (n = 11 of 154 patients) and 15.3% (n = 23 of 150 patients) in the control group and the intervention group, respectively, underwent surgery within 12 months of the intervention (P = .02).

In the ITT analysis, 15.5% (n = 26) of patients in the control group and 20.2% (n = 34) of patients in the intervention group received a recommendation for surgery within 6 months (P = .25). However, in the per-protocol analysis, the surgery recommendation rate did not differ significantly between the control group (15.6%; n = 24 of 154) and the intervention group (20.7%; n = 31 of 15). Results were similar after adjustment for study site.

"Decision aids provide high-quality information on treatment options while also clarifying the outcomes of treatment choice. In this way, they empower patients and facilitate communication and decision making," the authors write. "Decision aids are associated with increased patient knowledge, more realistic patient perceptions about the disease or treatment, less decisional conflict, fewer patients who are passive decision makers, fewer patients who remain indecisive after counseling, and improved concordance between patient values and treatment choices."

Dr Ibrahim reports receiving a Mid-Career Development Award from the National Institute of Arthritis and Musculoskeletal and Skin Disorders. The remaining coauthors have disclosed no relevant financial relationships.

JAMA Surg. Published online November 23, 2016.

    
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2012/3/12 下午 05:53:33

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