Validation of an educational booklet targeted to patients candidate for total knee arthroplasty

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial

IMPORTANCE

Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period.

OBJECTIVE

To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019.

INTERVENTIONS

Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR.

MAIN OUTCOMES AND MEASURES

The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale.

RESULTS

A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01671917.

Development and validation of education materials to reduce childhood blindness due to retinopathy of prematurity

BACKGROUND

Timely and appropriate follow-up appointments for infants at risk for retinopathy of prematurity (ROP) are very important to prevent blindness. Caregivers are important members of the ROP team, and their involvement is essential in ensuring optimal visual outcomes. This paper aimed to develop health information materials on ROP by a systematic process for better comprehensibility by the target audience of low literacy.

MATERIALS AND METHODS

It was a methodological study conducted at the neonatal intensive care unit of a tertiary care hospital, North India. The development and validation of educational materials was conducted in six steps. The study focused on both the knowledge of the target audience and on the validation of the educational materials by experts and caregivers of ROP eligible infants.

RESULTS

Most of the items (content, language, layout, motivation, and cultural appropriateness) were in either a suitable or adequate category. Only one item illustration was in the nonsuitable category. The mean final score of the leaflet after revision by experts was 9 (maximum score = 10). Regarding readability, The Flesch Reading Ease Score, Flesch-Kincaid Grade Level, and gunning fog index were found to be 72.5, 7.4, and 6.2, respectively. The leaflet was found to be suitable for the seventh grader. The mean knowledge score of the parents was 4 (maximum score-5).

CONCLUSION

The study showed satisfactory acceptance of the developed ROP information materials by caregivers and experts. A similar approach could be adopted for the development of other health information materials.

Preoperative information: Written first?

Patient information is now an ethical and legal obligation in France; it is the physician who is required to provide proof. The Law of March 4, 2002 and the code of ethics and main legal and regulatory texts are, however, imprecise on some points. Written documents, although not stipulated in law, are in practice essential, supplementing the indispensable oral information given by the surgeon in individual personalized interview. Patients remember only some of this information, and overestimate their own understanding of it. Written documents are therefore essential to compensate for this. Their contents need validation by scientific societies. In case of disagreement, the medical file is the essential means of assessing information quality, and should be kept up to date as rigorously as possible. A key document is the letter summarizing the preoperative consultation, validating surgery, which should be drawn up in a manner that meets the obligation to inform. Signed consent is not mandatory in law, but is necessary in practice and should be archived. For judges, proof of information is based on several elements: the complete structured letter to the patient and community physician plus the signed information sheet and consent form constitute solid evidence and all three should be included in the medical file. Information has now become a part of health-care in itself. In a context of increasing litigation, "defensive medicine" is still to be avoided but physicians should have their own check-lists so as to be in a position to prove delivery of structured information if called upon to do so. In the absence of proven information, patients can plead loss of chance and/or prejudice for lack of preparation and/or infringement of dignity, and claim damages from the courts.

Assessing an educational booklet for promotion of healthy lifestyles in sedentary adults with cardiometabolic risk factors

OBJECTIVES

1) To evaluate and improve the suitability and readability of an educational booklet designed for use in an intervention aimed at promoting healthy lifestyles as a way to manage cardiometabolic risk factors in adults with low levels of physical activity and 2) to check its acceptability to real end users.

METHODS

A 7-phase methodology was used. The evaluation committee (9 experts, 6 potential end users) scored the booklet using the Suitability Assessment of Materials (SAM) and health education material (HEM) questionnaires on two occasions (original and revised version). Acceptability was also assessed by 75 real end users after a lifestyle intervention.

RESULTS

The SAM and HEM scores of the revised booklet were respectively 10% (SD = 9%) and 10% (SD = 7%) higher than the original booklet scores. The revised version attained "superior" scoring in all questionnaires: SAM, 87% (SD = 8%); HEM, 3.5 (SD = 0.4) out of 4; Acceptability, 3.7 (SD = 0.4) out of 4.

CONCLUSIONS

The suitability and readability of an educational booklet-to promote a healthy lifestyle-were improved following a systematic peer-review evaluation prior to its use in an intervention.

PRACTICE IMPLICATIONS

Improving the suitability and readability of educational resources can have a positive impact on patient knowledge and awareness, and hence on intervention effectiveness.

Mixed qualitative and quantitative approach for validating an information booklet before total hip arthroplasty

OBJECTIVE

Providing patients with validated information before total hip arthroplasty may help lessen discrepancies between patients' expectations and the surgical result. This study sought to validate an information booklet for candidates for hip arthroplasty by using a mixed qualitative and quantitative approach based on a panel of patients and a sample of healthcare professionals.

METHODS

We developed a booklet in accordance with the standard methods and then conducted focus groups to collect the opinions of a sample of multidisciplinary experts involved in the care of patients with hip osteoarthritis. The number of focus groups and experts was determined according to the data saturation principle. A panel of patients awaiting hip arthroplasty or those in the immediate post-operative period assessed the booklet with self-reporting questionnaires (knowledge, beliefs, and expectations) and semi-structured interviews.

RESULTS

All experts and both patient groups validated the booklet in terms of content and presentation. Semi-structured interviews were uninformative, especially for post-operative patients. Reading the booklet significantly (P<0.001) improved the knowledge scores in both groups, with no intergroup differences, but did not affect beliefs in either patient group. Only pre-operative patients significantly changed their expectations.

CONCLUSION

Our mixed qualitative and quantitative approach allowed us to validate a booklet for patients awaiting hip arthroplasty, taking into account the opinions of both patients and healthcare professionals.

Prospective assessment of patients' knowledge and informational needs and of surgeon-to-patient information transfer before and after knee or hip arthroplasty

BACKGROUND

Patients are playing an increasingly large role in their own management and must therefore receive clear, complete, and comprehensible information. In the field of hip and knee arthroplasty, little is known about the level of patient knowledge and effectiveness of surgeon-to-patient information transfer. We therefore designed a prospective observational study with the objective of assessing four factors: patient knowledge during management, quality of information transfer, informational needs, and factors associated with the level of knowledge.

HYPOTHESIS

The level of patient knowledge changes during the management process.

PATIENTS AND METHODS

A prospective single-centre study was conducted between January 2014 and March 2015 during the outpatient visits and inpatient stays of 63 patients who underwent arthroplasty of the hip (n=36) or knee (n=27). A single observer attended all patient visits and recorded the information provided by the surgeon. Each patient completed a self-questionnaire after the outpatient visit (T1), at admission (T2), and at discharge after surgery (T3). Semi-quantitative scores were used to assess knowledge and informational needs. The effectiveness of information transfer was evaluated by comparing the information provided by the surgeon to the replies made by the patients.

RESULTS

The mean overall knowledge score (on a 0-42 scale) increased from 17.22±6.33 at T1 to 19.44±6.89 at T3 (P=0.0028). In contrast, knowledge about complications was better at T1 than at T3 (2.67±1.98 vs. 2.19±1.91; P<0.05). Agreement between information given by the surgeon and replies made by patients varied across items from 23% to 100%. The mean informational needs score (on a scale from 0 to 21) ranged from 3.67 to 4.83 and was higher at T3 than at T2 (4.83±3.77 vs. 3.67±4.86; P=0.03). The proportion of patients who wanted written information was higher at T3. Most patients sought information before the outpatient visit. At each step of the management process, the main areas about which the patients wanted information were the surgical procedure, the rehabilitation programme, and the prosthesis. Several socio-demographic or management-related factors influenced the level of knowledge. Thus, older age and lower educational attainment were associated with lower knowledge scores, whereas previous lower-limb orthopaedic surgery and amount of information provided by the surgeon were associated with higher knowledge scores. Knowledge scores were not associated with being employed vs. retired, gender, replacement of a hip vs. a knee, the surgeon, or being accompanied by another person.

DISCUSSION

Our study is original in that we assessed changes in patient knowledge during the management process for hip or knee arthroplasty. The level of patient knowledge was fairly low and varied considerably across individuals and time points in the management process. These data highlight the importance of providing patients with information throughout their management and particularly at discharge, when the desire for information seems greatest.

LEVEL OF EVIDENCE

IV, prospective observational study with no control group.

Randomized blinded trial of standardized written patient information before total knee arthroplasty

Background

The effect of patient education before total knee arthroplasty (TKA) is controversial. No consensus exists about the optimal content of educational interventions. In a previous study, we developed and validated an educational booklet on the peri-TKA management of knee osteoarthritis.

Purposes

Our primary purpose was to evaluate the impact of the educational booklet on knowledge among patients awaiting TKA.

Patients and methods

This randomized controlled single-blind trial evaluated standard information by the surgeon with or without delivery of the educational booklet 4–6 weeks before primary noncomplex TKA in patients aged 55–75 years with incapacitating knee osteoarthritis. Patients were enrolled at a French surgical center between June 2011 and January 2012. A patient knowledge score was determined at baseline, on the day before TKA, and 3–6 weeks after TKA, using a self-administered questionnaire developed for our previous study. The assessor was blinded to group assignment.

Results

Of 44 eligible patients, 42 were randomized, 22 to the intervention and 20 to the control group, all of whom were included in the analysis. The groups were comparable at baseline. The intervention was associated with significantly better patient knowledge scores.

Conclusions

An educational booklet improves knowledge among patients awaiting TKA. A study assessing the impact of the booklet combined with a exercise program would be helpful.

Level of evidence

Level I, randomized controlled double-blind trial; see S1 CONSORT Checklist.

Trial registration

clinicaltrials.gov #NCT01747759