协助黑人患者增加膝关节置换的决定辅助


  【24drs.com】根据一篇多中心随机研究,相较于典型的教育手册,辅助决定之影片显著增加了膝盖骨关节炎(knee osteoarthritis,OA)黑人患者进行全膝关节置换(total knee replacement,TKR)手术的百分比达85%;这影片也使接受骨外科医师之TKR建议者增加达接近三分之一,不过,这项关联未达统计上的显著意义。
  
  研究者写道,以患者为中心的教育工具,如决定辅助,可帮助降低获得偏好敏感性手术治疗如全膝关节置换术的种族差异。
  
  宾州健康权益研究暨促进中心、费城退伍军人事务医学中心、宾州大学Perelman医学院医学系、一般内科Said A. Ibrahim医师等人在11月20日的JAMA Surgery期刊在线发表他们的结果。
  
  在美国,骨关节炎是失能的主要原因,黑人成人的盛行率和白人成人一样高,不过,之前的研究显示,尽管TKR有其效益,黑人进行TKR的比率显著低于白人同龄者。
  
  为了降低此项差异,Ibrahim医师等人纳入336名50岁以上、患有慢性频发膝盖疼痛的黑人患者,纳入基准是依据全国健康与营养检视调查问卷(National Health and Nutrition Examination Survey questionnaire)、西安大略麦克马斯特大学骨关节炎分数达39分以上且有放射线证据显示膝盖OA。
  
  这篇研究排除了曾有主要关节置换、末期疾病、医师诊断为发炎性关节炎、腿部义肢、认知障碍、缺乏家庭电话服务、或对选择性置换手术有禁忌症的患者。
  
  随机指派患者到介入组(n = 168人),观看40分钟的TKR手术利弊解说影片,或者是指派到对照组(n = 168人),接受标准的教育手册。这项研究的主要结果是,在介入的12个月内接受TKR手术和/或在介入的6个月内接受骨外科医师的TKR手术建议。
  
  在治疗意向(ITT)分析中,对照组有7.7%(n = 13/168)、介入组有14.9% (n = 25/168)的患者在介入后12个月内进行手术。在符合方案分析中,对照组与介入组分别有7.1% (n = 11/154)与15.3% (n = 23/150)的患者在介入后12个月内进行手术(P = .02)。
  
  在ITT分析中,对照组有15.5% (n = 26)、介入组有20.2% (n = 34)的患者在6个月内接受手术建议(P = .25),不过,在符合方案分析中,对照组(15.6%;n = 24/154)与介入组(20.7%;n = 31/150)的接受手术建议比率并无显著差异,校正研究地点之后,结果相似。
  
  作者们写道,决定辅助提供关于治疗选择的高质量信息,同时还厘清治疗选择的结果。透过这种方式,他们授权患者并促进沟通和决定。决定辅助随著患者的知识而增加,患者对于疾病或治疗的看法更切实、更少的决策冲突、更少的被动决定型患者、更少的咨询后仍然不决定的患者,并改善患者价值和治疗选项之间的一致性。
  
  资料来源: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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膝盖置换缺乏长期的安全性和有效性资料
2012/3/12 下午 05:53:33

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