Before Knee Replacement, More Information Is Not Always Better

More information does not automatically produce a better decision. In a randomized study of patients with hip or knee osteoarthritis, a short, interactive decision aid produced higher knowledge scores than a long, detailed program, while surgical rates and other major outcomes were similar.

The lesson is not that patients should receive less information. The lesson is that education should be focused, understandable, and actually used.

Patients considering joint replacement are often given a large amount of material: booklets, videos, web pages, class schedules, consent forms, and lists of restrictions. Much of it may be accurate. That does not mean it will be read, understood, remembered, or connected to the patient's actual decision.

A useful decision aid should help the patient understand the diagnosis, the available options, the expected benefits, the important risks, and the practical demands of recovery. It should also help the patient identify what matters most in his or her own life.

The DECIDE-OA study was a multisite randomized comparative-effectiveness trial involving 1,124 patients with hip or knee osteoarthritis. Approximately 67% of the participants had knee osteoarthritis.

Patients were assigned to one of two educational approaches. The long decision aid included a detailed video and a booklet of more than 40 pages. The short decision aid was an interactive tool that could also be printed as a shorter brochure. Eight surgeons were also assigned either to usual care or to receive a report summarizing the patient's goals and treatment preference before the visit.

The researchers measured knowledge, informed patient-centered decisions, shared decision-making, surgery within six months, and surgeon satisfaction.

Before the surgeon visit, the short-decision-aid group had an average knowledge score approximately 9 percentage points higher than the long-decision-aid group. After the visit, the difference remained approximately 7 percentage points.

After the visit, 67.2% of the patients met the study's definition of an informed, patient-centered decision. That rate did not differ significantly between the short and long decision aids.

Approximately 60.5% underwent surgery within six months. Surgical rates did not differ significantly between the educational groups. The separate preference report provided to surgeons also did not measurably change the main outcomes.

Surgeons reported that 88.7% of the visits were normal in duration or shorter than normal. Patients who reviewed more of either decision aid generally had better knowledge.

The shorter tool did not improve knowledge because it omitted every difficult subject. It appears to have delivered the important material in a form patients were more likely to complete and understand.

The relationship between completion and knowledge is practical. A technically excellent 50-page booklet has limited value if the patient reads only the first few pages. A shorter tool can be more effective when it identifies the questions that actually affect the decision and presents them clearly.

The study also challenges a common concern that better decision support will automatically lengthen the visit or push patients toward or away from surgery. In this trial, the surgeons generally did not perceive longer visits, and the surgical rates were similar.

• It does not prove that all short educational material is better than all long material.
• It does not mean patients should receive incomplete information.
• It does not allow a handout or video to replace the surgeon-patient discussion or informed consent.
• It included both hip and knee patients rather than knee patients alone.
• There was no usual-care group that received no decision aid.
• The population was predominantly white and had relatively high literacy, which may limit generalizability.
• Many patients were excluded after randomization because they did not attend the visit.

Patients do not need more pages. They need the right information in the right order.

Before a decision about knee replacement, the patient should understand the diagnosis, what has already been tried, the realistic nonsurgical options, the expected benefit of surgery, the important risks, the recovery demands, and the functional goal that would make surgery worthwhile. The patient should also know what surgery cannot promise.

The decision aid should prepare the patient for the visit, not attempt to replace the visit. For patients in Oklahoma City, a clear orthopedic evaluation should connect the imaging and examination findings to the patient's symptoms and goals. Education is most useful when it leads to a better conversation.

• What activity can I no longer do because of the knee?
• What treatments have I already tried, and what happened with each one?
• What is the expected benefit of surgery for my specific diagnosis?
• What are the important risks and recovery demands?
• What result would make the operation worthwhile to me?

Good patient education should be complete, but it does not need to be bloated. In this study, a short decision aid produced better knowledge than a much longer program and did not appear to increase visit length or change surgical rates.

The goal is not to give the patient the largest packet. The goal is to help the patient understand the decision.

No. A decision aid can explain options and tradeoffs, but the recommendation still depends on the diagnosis, imaging, examination, symptom severity, prior treatment, medical risk, and personal goals.

Only when the material is understandable and actually reviewed. In this study, patients who completed more of either decision aid had better knowledge, but the shorter tool produced higher average knowledge scores.

Not necessarily. In this study, surgeons reported that most visits were normal in duration or shorter. Good preparation can make the discussion more focused rather than simply longer.

Source: Sepucha K, Bedair H, Yu L, et al. Decision Support Strategies for Hip and Knee Osteoarthritis: Less Is More. A Randomized Comparative Effectiveness Trial. J Bone Joint Surg Am. 2019;101:1645-1653. doi:10.2106/JBJS.19.00004.

This article is for general educational purposes and does not replace an individualized diagnosis or treatment recommendation. Medical decisions should be made with a qualified clinician who has reviewed the patient's history, examination, imaging, and goals.