Best of the Best Gen Surg - Pilot Randomized Control Trial Evaluating the Use of a Shared Decision Making Aid for Older Ventral Hernia Patients - Dr. Kushner

Shared decision making is defined as care that is evidence informed, respectful, and responsive to an individual patient's preferences

By the year 2050, the number of adults 60 years of age or older will at least double

Age-related risk factors and morbidities have been shown to predict mortality and morbidity following eventual hernia repair

In phase 1 of the GRAMPS program, age-related risk factors in the elective hernia population were demonstrated to be both common and present a real challenge to the hernia surgeon

The novel shared decision making tool was designed based on the Agency for Healthcare Research and Quality suggested framework for incorporating shared decision making into practice and included 5 key parts

The tool was designed to be completed in real time during the patient consultation and to act as a living document that patients could reference and bring to their surgery date or subsequent appointments

Patients were excluded if they were deemed to be a non-operative candidate despite potential future prehabilitation options or who had a documented history of cognitive impairment

During the 4 month trial enrollment period, 18 patients were consented and randomized, half to each of the experimental and control groups, with overall recruitment percentage greater than 95%

The median time of consultation was 9 minutes longer in the experimental group

There was higher retention of key hernia knowledge in the experimental group when patients were given a follow-up hernia quiz one week after the initial consultation

75% of patients in the experimental group perceived their visit as shared decision making as compared to only 50% in the control group when using the collaborate scale

There was a meaningful clinical decrease in the decisional conflict of patients in the experimental group, with a difference of 6 points on the decisional conflict scale

Previous groups have found that for every point decrease on the decisional conflict scale, there was an associated 19% less likelihood to blame doctors for poorer outcomes

The two most important treatment goals identified by patients in the experimental group were improving quality of life and preventing hernia recurrence

Only 1 patient previously had discussed their code status with their doctor, and only 33% had a documented power of attorney

100% of patients in the experimental group both enjoyed the shared decision making aid and found it to be a useful exercise when asked about it on exit interview

Patients eligible for the study were identified about a week or two before their first hernia clinic by looking at schedules of the three main hernia surgeons at the institution

Patients were called and told about the study looking at shared decision-making and that they would be randomized to either a newer tool or the standard shared decision-making visit that surgeons typically do

The IRB required telling patients after the fact that those in the control group were withheld the actual aid

For a 60-year-old gentleman with a primary 4 centimeter ventral hernia or primary umbilical hernia, asking 10 hernia surgeons might get 10 different answers on how to repair it

Different hernia repair approaches have potential for different quality of life for the patient in terms of how big the operation would be, the percentage of hernia recurrence, and potential options for the future

The next phase is a randomized controlled trial currently running with a condensed form of the shared decision-making aid

The most important parts of the aid were not actually going through all the decision-making with patients, but having it written down for the patient to take home and discuss with their loved ones