Surgeon Applications of Patient Preferences in Treatment Decision Making for First-Time Anterior Shoulder Dislocation

Brian C Lau; Carolyn A Hutyra; Benjamin Streufert; Shelby D Reed; Lori A Orlando; Joel C Huber; Dean C Taylor; Richard C Mather 3rd

doi:10.1177/2325967120966145

Surgeon Applications of Patient Preferences in Treatment Decision Making for First-Time Anterior Shoulder Dislocation

Orthop J Sports Med. 2020 Dec 4;8(12):2325967120966145. doi: 10.1177/2325967120966145. eCollection 2020 Dec.

Authors

Brian C Lau¹, Carolyn A Hutyra², Benjamin Streufert³, Shelby D Reed⁴, Lori A Orlando⁵, Joel C Huber⁶, Dean C Taylor¹, Richard C Mather 3rd¹

Affiliations

¹ Duke Sport Science Institute, Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
² Comprehensive Outcomes in Orthopaedics and Rehabilitation Data System, Duke Practice Transformation Unit, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
³ Mayo Clinic, Rochester, Minnesota, USA.
⁴ Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
⁵ Duke Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC, USA.
⁶ Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA.

Abstract

Background: Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions.

Purpose: To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon's treatment plan for FTASD.

Study design: Cross-sectional study.

Methods: Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions.

Results: A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making.

Conclusion: Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.

Keywords: decision analysis; first-time shoulder dislocation; patient preferences; shoulder instability.