Influences on individuals with osteoarthritis in deciding to undergo a hip or knee joint replacement: A qualitative study

Better Before-Better After: A Qualitative Phenomenology Study of Older Adults' Experiences With Prehabilitation Before Total Hip Replacement

Total hip replacement is considered a successful intervention for pain relief and improved function. However, poor presurgery physical function may increase the likelihood of delayed postsurgery recovery. The purpose of this study was to describe community-dwelling older adults' experiences with a prehabilitation program (preoperative exercise) before total hip replacement. Four participants were interviewed 13 and 15 weeks postsurgery. The interviews were recorded, transcribed, and analyzed with systematic text condensation. Physical, mental, and social limitations were, to a higher or lesser degree, part of the participants' life presurgery. The results indicate that tailored close supervised training presurgery increased the participants' amount of and adherence to exercise, confidence, and sense of control. The participants had a positive experience of increased strength during the training period and gained motivation to perform progressive training. The exercise program helped the participants be physically and mentally prepared. The results indicate that close supervised prehabilitation in community-dwelling older adults undergoing total hip replacement can contribute to improved function and increase the level of activity and self-efficacy postsurgery.

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

Patient preferences and decision-making when considering surgery for musculoskeletal disorders: A mixed methods systematic review

INTRODUCTION

The burden of Musculoskeletal disorders (MSD) is large. Surgery is an important management option but the factors that shape patients' surgical decisions are not well understood. As prior reviews have explored only single data types or conditions, a mixed methods appraisal across the musculoskeletal spectrum was undertaken.

METHODS

A mixed-methods systematic, convergent segregated approach was used, with PubMed, Cumulated Index to Nursing and Allied Health Literature (CINHAL), Embase and PsycINFO searched to identify studies of adult patients' decisions about whether to undergo surgery. A narrative synthesis was conducted, with identified themes integrated across quantitative, qualitative and mixed-methods studies.

RESULTS

Forty-six studies were included (24 quantitative, 19 qualitative and three mixed methods), with four decision-making themes identified (symptoms, sociodemographic and health factors, information and perceptions). Decision-making involves a complex interaction of individual sociodemographic, health and symptom information, integrated with individual perceptions of candidacy and surgical expectations. While most studies investigated hip and knee surgery, across all included conditions, patients are more likely to favour surgery if symptoms and/or dysfunction are higher, and if perceptions of surgical candidacy and processes (outcomes, inconvenience, and risk) are favourable. Other factors including age, general health, race, financial context, professional and non-professional communication, and information sources also impact decision-making but exert a less consistent impact upon the propensity to prefer surgery.

CONCLUSION

Patients are more likely to choose surgery for MSD when they have higher levels of symptoms or dysfunction and positive perceptions of surgical suitability and expectations. Other factors important to individuals, have a less consistent impact upon the propensity to prefer surgery. These findings have potential to aid the efficient referral of patients to orthopaedics. More research is needed to validate these findings across the spectrum of MSD.

A synthesis of qualitative research to understand the complexity behind treatment decision-making for osteoarthritis

Objective

Osteoarthritis is the most common joint disease with treatment involving a multidisciplinary approach with pharmacological, physical therapies and surgery as options. Qualitative research can help us to understand the complexity of managing health conditions and this understanding plays a role in good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis, including decision making about joint replacement.

Methods

We comprehensively searched 4 bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10 ​123 titles, 548 abstracts, and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world.

Results

We developed 7 themes: Becoming your own expert can be hard work; Living has become a careful balancing act; Medication is a double-edged sword; I have other things in my life to consider; You have to weigh up the odds of surgery; Surgery is the only effective option; and Surgery will give me a chance to live now. These findings have been drawn into a conceptual model reflecting a complex balancing act with tensions underpinning treatment decision making.

Conclusions

Osteoarthritis is framed as a world where patients become their own expert about their management and healthcare choices. Our conceptual model highlights key tensions underpinning treatment decision-making. These findings provide clinicians with insight of the complex nature of these decisions and how they can help patients through shared decision making.

Factors affecting decision-making for knee arthroplasty in patients with osteoarthritis

OBJECTIVE

Identifying factors affecting decision-making for knee arthroplasty in patients with knee osteoarthritis is critically important for pain relief, improving in knee function and reaching an optimal outcome. When decision-making is hurried or delayed, surgery may not occur in time, which complicates the surgery and increases its complications. This study was conducted to investigate the factors influencing decision-making for knee arthroplasty.

METHODS

This study is a qualitative study and inductive content analysis method. This study enrolled 22 patients undergoing knee arthroplasty selected through purposive sampling. Data were collected through semi-structured in-depth interviews and analyzed using inductive content analysis.

RESULTS

Data analysis yielded three categories: hope to return to normal life, encouragement and recommendations, and trust and assurance.

CONCLUSION

To make better treatment-related decisions and achieve better outcomes based on the patient's values and wishes, it is necessary for the treatment team to increase its interactions and establish stronger communication with patients to make their expectations more realistic and help them understand the risks. They should also make efforts to increase patients' knowledge about the advantages and disadvantages of surgery and clarify what is important to them in decision-making.

Time to Total Knee Arthroplasty after Intra-Articular Hyaluronic Acid or Platelet-Rich Plasma Injections: A Systematic Literature Review and Meta-Analysis

Intra-articular (IA) hyaluronic acid (HA) and platelet-rich plasma (PRP) injections are increasingly being prescribed for knee osteoarthritis (KOA). However, failure of the medical treatment may result in total knee arthroplasty (TKA). We wondered if IA HA or PRP injections (intervention) may delay the time to TKA (outcome) among KOA patients (population), compared to KOA patients not receiving these injections (comparator). For this systematic literature review (SLR) and meta-analysis, we selected observational studies with at least one group of patients receiving IA HA or PRP and with TKA data available. The main outcome was time from the diagnosis of KOA to TKA. We included 25 articles in the SLR (2,824,401 patients) and four in the meta-analysis. The mean strengthening the reporting of observational studies in epidemiology (STROBE) score was 63%. For patients receiving versus not receiving HA injections, the delay between a declared diagnosis of KOA to TKA was increased by 9.8 months (95% CI (8.2-11.4)). As compared with standard of care, the effect size of HA injections for this outcome was 0.57 (95% CI (0.36-0.76)). Only one study described a median time from PRP injections to TKA of 4.1 years (range 0.3-14.7). IA HA injections were associated with increased time to TKA. Causality cannot be concluded because of missing confounder factors as comorbidities. Data were insufficient to conclude any effect of PRP injections on TKA delay.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with osteoarthritis pain

ABSTRACT

Osteoarthritis pain affects the lives of a large number of people around the world. Understanding other people's experience is integral to effective care and qualitative research can have an important part to pay in education and good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis in order to incorporate this knowledge into an educational resource. We comprehensively searched four bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10123 titles, 548 abstracts and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world. We developed 7 themes from more than 600 findings: it is part of my life's tapestry; (yet) it is consuming me; it constrains my body and my occupations; I am becoming separated yet dependent; I accept, but I will not let it define me; (yet) this makes me feel less than the person I was. Our findings highlight the profound impact that osteoarthritis can have on people's lives and the struggle to hold onto a sense of self. They indicate that recognising these losses, and taking osteoarthritis seriously, is an integral part of effective healthcare. This finding may be transferable beyond this condition.

Partial or total knee replacement? Identifying patients' information needs on knee replacement surgery: a qualitative study to inform a decision aid

Purpose

For patients with end-stage knee osteoarthritis, joint replacement is a widely used and successful operation to help improve quality-of-life when non-operative measures have failed. For a significant proportion of patients there is a choice between a partial or total knee replacement. Decision aids can help people weigh up the need for and benefits of treatment against possible risks and side-effects. This study explored patients’ experiences of deciding to undergo knee replacement surgery to identify information priorities, to inform a knee replacement decision aid.

Methods

Four focus groups were held with 31 patients who were candidates for both partial and total knee replacement surgery. Two focus groups included patients with no prior knee replacement surgery (pre-surgery); two with patients with one knee already replaced and who were candidates for a second surgery on their other knee (post-surgery). Data were analysed using Framework Analysis.

Results

Participants described a process of arriving at ‘readiness for surgery’ a turning point where the need for treatment outweighed their concerns. Referral and personal factors influenced their decision-making and expectations of surgery in the hope to return to a former self. Those with previous knee surgery offered insights into whether their expectations were met. ‘Information for decisions’ details the practicality and the optimal timing for the delivery of a knee replacement decision aid. In particular, participants would have valued hearing about the experiences of other patients and seeing detailed pictures of both surgical options. Information priorities were identified to include in a decision aid for knee replacement surgery.

Conclusions

Patients’ experiences of surgical decision-making have much in common with the Necessity-Concerns Framework. Whilst originally developed to understand drug treatment decisions and adherence, it provides a useful lens to understand decision-making about surgery. The use of a decision aid could enhance decision-making on knee replacement surgery. Ultimately, patients’ understanding of the risks and benefits of both surgical options could be improved and in turn, help informed decision-making. The knee replacement decision aid is perceived as a useful tool to be associated with other detailed information resources as recommended.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02381-9) contains supplementary material, which is available to authorized users.

Development and validation of a caregiving needs inventory for family members before their older relative's knee joint-replacement surgery

PURPOSE

This study had two purposes: to develop an instrument for assessing family members' caregiving needs before their older relative's knee joint-replacement surgery and to determine instrument psychometrics.

METHODS

In phase 1 of this validation study, we generated 34 items based on previous interviews with 138 family caregivers of patients with knee osteoarthritis (OA), an intensive literature review, and the authors' clinical experiences. In phase 2, we examined the content and face validities of the 34-item Family Members' Caring Needs Inventory (inventory) to develop a 32-item inventory. In phase 3, 150 family members of outpatients with knee OA were recruited from three hospitals in northern Taiwan and surveyed with the inventory to determine its internal consistency reliability and test-retest reliability.

RESULTS

The final 30-item inventory had excellent content and face validities. Its factor analysis yielded a five-factor solution, accounting for 82.9% of the variance. The inventory had Cronbach's α = 0.97 and intraclass correlation coefficient = 0.93, indicating very high internal consistency reliability and test-retest reliability.

CONCLUSIONS

The inventory was perceived as easy to complete and yielded highly acceptable validity and reliability levels. After cross-cultural adaptation, this tool may be used to assess family members' caregiving needs before their relative's knee-replacement surgery.IMPLICATIONS FOR REHABILITATIONThe role of family members and spouses in supporting patients with osteoarthritis (OA) is crucial.After cross-cultural adaptation, the Family Members' Caring Needs Inventory may be used by health care providers to assess and provide relevant information to meet the needs of family members caring for an older relative with knee OA.This assessment and specific caregiving information for family members of older knee OA patients may promote patients' quality of life and decrease their OA-related burden.

Experiences of pre- and postoperative information among patients undergoing knee arthroplasty: a systematic review and narrative synthesis

Purpose: The aim of this review was to identify and synthesize knowledge of how patients undergoing knee arthroplasty experience pre- and postoperative information provided by healthcare professionals.Materials and methods: A systematic review and narrative synthesis was conducted in accordance with Popay et al.'s guidelines which involve 1) developing a preliminary synthesis; 2) exploring relationships; and 3) assessing the robustness of the synthesis. Qualitative and quantitative studies were considered for inclusion, and a systematic, extensive search was conducted in scientific databases.Results: A total of 31 studies were included in this review. The analysis resulted in five synthesized themes: 1) Support in the decision to undergo surgery; 2) Confidence versus uncertainty in the preparation for surgery; 3) Prerequisites for feeling secure before discharge; 4) Struggling through rehabilitation at home; and 5) Unmet expectations and endeavoring to accept realities.Conclusions: The findings illustrate the complexities of patients' experiences of information from healthcare professionals and its significance for how they manage challenges throughout the surgical care pathway. Information from healthcare professionals influences patients' knowledge, skills and confidence in the journey through knee arthroplasty. Therefore, it is important that healthcare professionals recognize patients' support requirements and adapt information to their individual needs.Implications for rehabilitationHealthcare professionals should encourage more dialog with patients and adapt information to their individual circumstances and needs throughout the surgical care pathway.It is important that healthcare professionals provide ongoing information and repeat information throughout the entire surgical care pathway in order to facilitate predictability and improve patients' ability to comprehend and assimilate information.Improved access to information and advice from healthcare professionals following knee arthroplasty will offer patients reassurance and increase their confidence in managing postoperatively at home.Patients who require enhanced information and guidance from healthcare professionals need to be identified in order to support their progress and achieve the best possible postoperative outcomes.

Decision Support for Joint Replacement: Implications for Decisional Conflict and Willingness to Undergo Surgery

Objectives

The present study investigates age differences in the types of decision support that total joint replacement (TJR) candidates desire and receive when making the decision to pursue surgery. We consider the social structural (relationship to the patient) and experiential factors (network members' experience with TJR) that influence individuals' support preferences and the interactions of these factors with age. We also examine whether a lack of support is linked with increased decisional conflict and reduced willingness to undergo surgery.

Method

A telephone survey was conducted with 100 individuals (aged 40+) who were contemplating knee or hip replacement.

Results

TJR candidates desired and received decision support from health care providers, family members, and individuals who had previously undergone TJR. They reported higher deficits in informational and emotional support than in instrumental support. Overall, a lack of instrumental support was associated with greater decisional conflict; a lack of instrumental support and a lack of informational support were associated with reduced willingness to undergo TJR.

Discussion

Our findings point to the importance of involving both formal and informal network members in TJR discussions, and the need for informational guidance and practical assistance to reduce decisional conflict and uncertainty among individuals considering TJR.

Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Health Care Access Matters

OBJECTIVE

To determine if severity of osteoarthritis-related knee pain is associated with a willingness to undergo total knee replacement (TKR) and whether this association is confounded or modified by components of socioeconomic status and health care coverage.

METHODS

Cross-sectional analysis was conducted among 3,530 Osteoarthritis Initiative study participants. Logistic regression models were used to assess the effect of knee pain severity (where 0 = none, 1-3 = mild, 4-7 = moderate, and 8-10 = severe) on willingness to undergo TKR. Stratified analyses were conducted to evaluate whether socioeconomic status and health care coverage modify the effect of knee pain severity on willingness.

RESULTS

Participants with severe knee pain, compared to participants without pain, were less willing to undergo TKR (odds ratio [OR] 0.73, 95% confidence interval [95% CI] 0.57-0.93). This association was attenuated when adjusted for age, sex, comorbidity, depression, health insurance coverage, prescription medicine coverage, health care source, education, income, employment, race, and marital status (adjusted OR 0.92, 95% CI 0.68-1.24). The odds of willingness to undergo TKR were significantly lower in those with the highest level of pain, compared to those without pain, among participants without health insurance (adjusted OR 0.08, 95% CI 0.01-0.56), but not among those with health insurance (adjusted OR 1.03, 95% CI 0.73-1.38), when adjusted for demographic, clinical, health care access, and socioeconomic factors (P = 0.015). However, <5% of participants were without health insurance.

CONCLUSION

Among participants without health insurance, severe knee pain was paradoxically associated with less willingness to undergo TKR. Policies that improve access to quality health care may affect patient preferences and increase utilization of TKR surgery among vulnerable populations.

A qualitative study of factors underlying decision making for joint replacement among African Americans and Latinos with osteoarthritis

To support patients in making decisions that align with their unique cultural beliefs, an understanding of factors underlying patient preferences is needed. We sought to identify psychosocial factors that influenced decision making among African-American and Hispanic patients referred for knee or hip arthroplasty. Thirty-six participants deciding on surgery were interviewed. Responses were audio-taped, transcribed, and read. Codes were assigned to the raw data and then clustered into categories that were analyzed to yield overarching themes. This process was repeated independently by two corroborators. Six categories described the mental calculations made in patients' decision-making processes: 1) self-assessment of fit for surgery based on age and comorbidity, 2) research and development of mental report cards of their surgeons, 3) reliving of social network experiences, 4) reliance on faith and spirituality for guidance, 5) acknowledgment of fear and anxiety, and 6) setting expectations for recovery. This study advanced the understanding of how decisions about joint replacement are constructed and identified cultural levers that can be targeted for intervention. Developing culturally tailored health information that addresses some of our findings and disseminating messages through social networks may reduce the underutilization of joint replacement among racial and ethnic minority populations.

Reasons for Treatment Choices in Knee and Hip Osteoarthritis: A Qualitative Study

OBJECTIVE

Conservative treatment modalities in osteoarthritis (OA) of the hip or knee are underused, whereas the demand for surgery is rising substantially. To improve the use of conservative treatment modalities, a more in-depth understanding of the reasons for patients' treatment choices is required. This study identifies the reasons for choice of treatment in patients with hip or knee OA.

METHODS

Semistructured in-depth interviews with 24 OA patients were held. Stratified purposive sampling was used to enrich data variation. Interviews were transcribed verbatim and subsequently coded using a thematic approach. Two independent researchers reflected on, compared, discussed, and adjusted the coding.

RESULTS

Various treatment modalities were discussed by respondents: medication, exercise, physical therapy, injections, surgery, complementary, and alternative treatment. Four key themes underlying the choice for or against a treatment modality for OA were identified: 1) treatment characteristics: expectations about its effectiveness and risks, the degree to which it can be personalized to a patient's needs and wishes, and the accessibility of a treatment; 2) personal investment in terms of money and time; 3) personal circumstances: age, body weight, comorbidities, and previous experience with a treatment; and 4) support and advice from the patient's social environment and health care providers.

CONCLUSION

The 4 identified key themes enhance the insight of health care providers into the widespread reasons influencing patients' treatment choices for knee or hip OA. This knowledge can be used in clinical practice to aid shared decision making, which may lead to optimized treatment choices for both conservative and surgical treatment.

Trajectories of need: understanding patients' use of support during the journey through knee replacement

PURPOSE

To explore how the process of undergoing and recovering from knee replacement surgery alters patients' experiences and use of their support networks.

METHODS

Ten patients having knee replacement surgery for osteoarthritis were invited to take part in in-depth interviews prior to surgery and 2-4 weeks, 6 and 12 months post-operatively. Transcripts were analyzed using Interpretative Phenomenological Analysis.

RESULTS

Three superordinate themes were identified: (1) relationships with health professionals over the knee replacement journey; (2) implications for informal relationships and support networks and (3) providing support to others.

CONCLUSIONS

Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type and level of support people receive from others, and can also change the assistance that they themselves are able to offer. Findings highlight the value of the concept of interdependence to our understanding of participants' experiences. Activity undertaken by informal support networks assists participants to cope with the consequences of osteoarthritis and surgery, and fills in the gap when more formal support is lacking. However, it is essential that provision of care is individually tailored and that formal support is adequate at times when informal support networks are unavailable. Implications for Rehabilitation Activity undertaken by informal support networks can help patients who undergo knee replacement cope with the consequences of their operation; filling the void when support from health professionals is lacking. Contact with health professionals after surgery enhances confidence and offers reassurance; helping to facilitate the recovery process from knee replacement. Findings highlight, from patients' own perspectives, the potential value of post-operative physiotherapy received soon after surgery and the possible role of long-term follow up. Missing or ill-timed support from health professionals can have negative psychosocial consequences for patients going through joint replacement.

You'll know when you're ready: a qualitative study exploring how patients decide when the time is right for joint replacement surgery

Background

While some studies have identified patient readiness as a key component in their decision whether to have total joint replacement surgery (TJR), none have examined how patients determine their readiness for surgery. The study purpose was to explore the concept of patient readiness and describe the factors patients consider when assessing their readiness for TJR.

Methods

Nine focus groups (4 pre-surgery, 5 post-surgery) were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for TJR or had undergone TJR. The method of analysis was qualitative thematic analysis.

Results

There were 65 participants, 66% female and 34% male, 80% urban, with an average age of 65 years (SD 10). Readiness reflected both the surgeon’s advice that the patient was clinically ready for surgery and the patient’s feeling that they were both mentally and physically ready for surgery. Mental readiness was described as an internal state or feeling of being ready or prepared while physical readiness was described as being physically fit and in good shape for surgery. Factors associated with readiness included: 1) pain: its severity, the ability to cope with it, and how it affected their quality of life; 2) mental preparation; 3) physical preparation; 4) the optimal timing of surgery, including age, anticipated rate of deterioration, prosthesis lifespan and the length of the waiting list.

Conclusions

Patient readiness should be assessed prior to TJR. By assessing patient readiness, health professionals can elucidate and deal with concerns and fears, understand and calibrate expectations, assess coping strategies, and use this information to help determine optimal timing, both before and after the surgical consultation.

Conceptualising time before surgery: the experience of patients waiting for hip replacement

Interpretations of time underlie patients' experiences of illness and the way in which the National Health Service (NHS) is organised. In the NHS, achieving short waiting times for treatment is seen as important, and this is particularly evident in relation to chronic conditions where the time waiting in care from onset of symptoms to successful management can last months and years. One example of a chronic condition with high prevalence is osteoarthritis, estimated to affect 10% of people aged over 55 years in the UK. Osteoarthritis of the hip is particularly common, and treatments include exercise and medication. If these options do not provide enough relief from pain and functional difficulties, then joint replacement may be considered. With over 70,000 such operations conducted every year in England and Wales, processes relating to waiting times impact on many patients. This article explores how 24 patients with osteoarthritis experience time during the lead up to hip replacement surgery. We draw on data collected during longitudinal in-depth interviews with patients a median of 9.5 days before surgery and at two to four weeks post-operatively. Transcripts of audio-recorded interviews were imported into Atlas.ti^® and inductive thematic analysis undertaken. Increasing pain and deterioration in function altered the experience of time during the journey towards hip replacement. Patients made essential changes to how they filled their days. They experienced lost and wasted time and faced disruption to the temporal order of their lives. A surgical date marked in the calendar became their focus. However, this date was not static, moving because of changing perceptions of duration and real-time alterations by the healthcare system. Findings highlight that patients' experience of time is complex and multi-dimensional and does not reflect the linear, monochronic conceptualisation of time embedded in the healthcare system.

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Waiting for hip replacement disrupts the temporal order of patients' lives.

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Patients' perceptions of time are multi-dimensional and complex.

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Experiences of time differ from health services' monochronic construction of time.

Contributions of Second Opinions, Outcome Forecasts, and Testimonials to Patient Decisions about Knee Replacement Surgery

BACKGROUND

Decision aids are now a well-established means of supporting patients in their medical decision making. The widespread use of decision aids invites questions about how their components contribute to patient decisions.

OBJECTIVE

The objective of this study was to measure the importance of second opinions, patient-specific outcome forecasts, and patient testimonials relative to patient clinical and socioeconomic factors and the primary physician recommendation on the decision to undergo full knee replacement surgery to treat knee osteoarthritis.

METHODS

Middle-aged and older members of the RAND American Life Panel (N = 1616) chose whether to recommend surgery as a treatment for each of 3 hypothetical patients (vignettes) presented in a video-enhanced internet survey. Vignettes randomly sampled levels of scenario attributes.

RESULTS

Second opinions, person-specific outcome forecasts, and 2 consistent patient testimonials strongly affected respondents' decision making; a single testimonial, however, did not significantly affect decisions.

CONCLUSIONS

Information provided in a decision aid, including person-specific outcome forecasts and testimonials, can affect patient choices. The strong effect of testimonials and respondents' interest in reviewing them reinforces concerns about unwanted influence when testimonials are biased.

Predictors of outcomes of recovery following total hip replacement surgery: A prospective study

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Methods

Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score.

Results

The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012).

Conclusions

The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR.

Cite this article: Bone Joint Res 2013;2:248–54.

Attitudes to knee osteoarthritis and total knee replacement in Arab women: a qualitative study

Background

Total Knee Arthroplasty (TKA) is offered to patients with knee osteoarthritis (OA) in the oil-rich countries in the Gulf region without adequate understanding of their perceptions, preferences or pain experiences. This study aimed to explore the pain experience and mobility limitation as well as the patient’s decision making process to undertake TKA among women with knee pain in the waiting list for surgery.

Methods

Five focus group discussions were conducted comprised of 39 women with severe knee OA from the waiting list for TKA in the only orthopaedic hospital in Kuwait. Discussions were recorded, transcribed and coded for themes to identify the factors considered to be important in decision-making for TKA.

Results

Experiencing knee pain was central to daily living and affected patients and their families. Mobility limitation was shaped by a strong sense of expected obligation to take care of the family. Two major sources of TKA delay were identified; one was due to late clinical advice to undergo TKA which was the result of receiving several consultations from different clinicians each of whom tried the medical management for OA. The second delay occurred after the clinical advice for TKA and was mainly due to ambivalence of patients because of fear of the operation and the lack of information about TKA that resulted in unclear expectations of the surgery.

Conclusions

Both verbal and written information about TKA should be provided as part of preoperative rehabilitation. This is critical to improve doctor-patient interactions and facilitate informed decision about the procedure and thus achieve patient-centered healthcare.

How do patients with end-stage ankle arthritis decide between two surgical treatments? A qualitative study

OBJECTIVE

To examine how patients decide between ankle fusion and ankle replacement in end-stage ankle arthritis.

DESIGN

Purposive patient selection, semistructured interviews, thematic analysis.

SETTING

Royal National Orthopaedic Hospital, Stanmore, UK.

PARTICIPANTS

14 patients diagnosed with end-stage ankle osteoarthritis.

RESULTS

We interviewed 6 men and 8 women with a mean age of 58 years (range 41-83). All had opted for surgery after failure of at least 6 months of conservative management, sequentially trading-off daily activities to limit the evolving pain. To decide between two offered treatments of ankle fusion and total ankle replacement (TAR), three major sources informed the patients' decision-making process: their surgeon, peers and the internet. The treating surgeon was viewed as the most reliable and influential source of information. Information gleaned from other patients was also important, but with questionable reliability, as was information from the internet, both of which invariably required validation by the surgeon and in some cases the general practitioner.

CONCLUSIONS

Patients seek knowledge from a wealth of sources including the internet, web forums and other patients. While they leverage each of these sources to guide decision-making, the most important and influential factor in governing how patients decide on any particular surgical intervention is their surgeon. A high quality doctor-patient relationship, coupled with clear, balanced and complete information is essential to enable shared decision-making to become a standard model of care.

Determinants of demand for total hip and knee arthroplasty: a systematic literature review

BACKGROUND

Documented age, gender, race and socio-economic disparities in total joint arthroplasty (TJA), suggest that those who need the surgery may not receive it, and present a challenge to explain the causes of unmet need. It is not clear whether doctors limit treatment opportunities to patients, nor is it known the effect that patient beliefs and expectations about the operation, including their paid work status and retirement plans, have on the decision to undergo TJA. Identifying socio-economic and other determinants of demand would inform the design of effective and efficient health policy. This review was conducted to identify the factors that lead patients in need to undergo TJA.

METHODS

An electronic search of the Embase and Medline (Ovid) bibliographic databases conducted in September 2011 identified studies in the English language that reported on factors driving patients in need of hip or knee replacement to undergo surgery. The review included reports of elective surgery rates in eligible patients or, controlling for disease severity, in general subjects, and stated clinical experts' and patients' opinions on suitability for or willingness to undergo TJA. Quantitative and qualitative studies were reviewed, but quantitative studies involving fewer than 20 subjects were excluded. The quality of individual studies was assessed on the basis of study design (i.e., prospective versus retrospective), reporting of attrition, adjustment for and report of confounding effects, and reported measures of need (self-reported versus doctor-assessed). Reported estimates of effect on the probability of surgery from analyses adjusting for confounders were summarised in narrative form and synthesised in odds ratio (OR) forest plots for individual determinants.

RESULTS

The review included 26 quantitative studies-23 on individuals' decisions or views on having the operation and three about health professionals' opinions-and 10 qualitative studies. Ethnic and racial disparities in TJA use are associated with socio-economic access factors and expectations about the process and outcomes of surgery. In the United States, health insurance coverage affects demand, including that from the Medicare population, for whom having supplemental Medicaid coverage increases the likelihood of undergoing TJA. Patients with post-secondary education are more likely to demand hip or knee surgery than those without it (range of OR 0.87-2.38). Women are as willing to undergo surgery as men, but they are less likely to be offered surgery by specialists than men with the same need. There is considerable variation in patient demand with age, with distinct patterns for hip and knee. Paid employment appears to increase the chances of undergoing surgery, but no study was found that investigated the relationship between retirement plans and demand for TJA. There is evidence of substantial geographical variation in access to joint replacement within the territory covered by a public national health system, which is unlikely to be explained by differences in preference or unmeasured need alone. The literature tends to focus on associations, rather than testing of causal relationships, and is insufficient to assess the relative importance of determinants.

CONCLUSIONS

Patients' use of hip and knee replacement is a function of their socio-economic circumstances, which reinforce disparities by gender and race originating in the doctor-patient interaction. Willingness to undergo surgery declines steeply after the age of retirement, at the time some eligible patients may lower their expectations of health status achievement. There is some evidence that paid employment independently increases the likelihood of operation. The relative contribution of variations in surgical decision making to differential access across regions within countries deserves further research that controls for clinical need and patient lifestyle preferences, including retirement decisions. Evidence on this question will become increasingly relevant for service planning and policy design in societies with ageing populations.

Individuals' expectations and challenges following total hip replacement: a qualitative study

PURPOSE

Hip replacements are one of the most common operations for individuals with hip osteoarthritis. There have been numerous quantitative studies investigating the recovery from joint replacement surgery and these show how effective and satisfied patients are. However, little qualitative work has been conducted to explore patients' actual experiences. Therefore, this study aimed to detail the experiences of individuals undergoing a total hip replacement (THR) to determine whether their expectations were met.

METHOD

The qualitative study was nested within a longitudinal study (n = 215) that was investigating biomedical and psychosocial outcomes from THR. We interviewed a purposive sample of individuals (n = 25) 6 months after THR to explore their experiences of having a THR.

FINDINGS

Participants were aged 48-82 years. They felt disabled following the THR and some had unrealistic expectations of recovery. Most of them received minimal information and health professional support. Participants had to overcome a number of challenges such as diminished confidence, frustration over slow progress and reduced physical functioning.

CONCLUSION

Individuals undergoing THR need to have the opportunity to discuss their expectations of THR, so there is no "false optimism". Support requirements, following THR, need to be reviewed as they were often underestimated by patients and health professionals.

Factors associated with physical activity in patients with osteoarthritis of the hip or knee: a systematic review

OBJECTIVE

To give an overview of factors related to the level of physical activity in patients with hip or knee osteoarthritis (OA).

METHODS

An extensive systematic literature search was conducted in PubMed, CINAHL and Embase. Inclusion criteria were: studies on patients with a diagnosis of OA of hip and/or knee, studies describing factors related to physical activity (objective or subjective), full length articles that were published in Dutch, German or English language. Two reviewers independently assessed the methodological quality. A best-evidence synthesis was performed for factors which were investigated in two or more studies.

RESULTS

Eight studies were included, all with a cross-sectional design (five high quality and three low quality studies), resulting in, at most, limited evidence in the best-evidence synthesis. For patients with knee OA there is limited evidence that a lower level of physical function is associated with a lower level of physical activity. There is also limited evidence that depression is not associated with the level of physical activity. For patients with hip OA there is limited evidence that higher age, higher body mass index (BMI) and a low level of physical function is associated with a low level of physical activity.

CONCLUSION

A high age (hip OA), a high BMI (hip OA) and a low level of physical function (both hip and knee OA) are related to a low level of physical activity. However, the level of evidence was only limited. Before new strategies and interventions to increase physical activity in patients with OA can be developed, high quality longitudinal studies are needed to get more insight in the causality between factors and low levels of physical activity.

GP referral of patients with osteoarthritis for consideration of total joint replacement: a longitudinal study

BACKGROUND

Individuals with hip or knee osteoarthritis (OA) are referred to orthopaedic surgeons if considered by their GP as potential candidates for total joint replacement (TJR). It is not clear which patients end up having this surgery.

AIM

The aim of the study was to investigate symptom variation in individuals with OA newly referred by GPs to an orthopaedic surgeon for consideration for TJR, and to determine the predictors of having this procedure.

DESIGN AND SETTING

A longitudinal study of patients at a regional orthopaedic centre with follow-up at 3, 6, and 12 months by postal questionnaire.

METHOD

GP referrals of patients with OA to orthopaedic surgeons were consecutively sampled. Of the 431 eligible patients, 257 (59.6%) were recruited. Validated measurement tools were used to measure pain, physical functioning, severity of OA, and health-related quality of life.

RESULTS

Over half the participants were in constant pain, taking pain medication more than once per day. Only 67 of 134 (50%) hip and 40 of 123 (33%) knee patients had a TJR within 12 months. Those who had a replacement had been diagnosed with OAfora shorter time, reported more frequent pain, were more likely to use a walking stick, and had worse pain, stiffness, and physical functioning.

CONCLUSION

Many individuals considered for TJR ultimately may not have surgery, and more effective strategies of management need to be developed between primary and secondary care to achieve better outcomes and to improve quality of care.

Chronic diseases influence major life changing decisions: a new domain in quality of life research

The purpose of this review is to identify knowledge about the influence of chronic disease on major life changing decisions (MLCDs). This review was carried out in three stages: identification of key search terms; selection of databases and searching parameters; and evaluation of references. Only two articles matched the main search term 'major life changing decisions'. No article reviewed or measured the influence of chronic disease on major life changing decisions. However, 76 articles and various sections of seven books were identified that provided insight into this area and these are reviewed in detail. This literature review has brought together previously scattered information on chronic disease impact on important patient life decisions. These include decisions related to having children, marriage and divorce, job and career choice, social life, holidays, travelling and education. Lifestyle decisions viewed by patients as major decisions are also documented. The influence of cancer on life decisions is discussed, as are affected life decisions of other family members. Very little information is available about the long-term impact of chronic disease on patients' lives and methodology to assess long-term impact is incomplete. This review points to a novel dimension to health-related outcome research, the impact of chronic disease on major life changing decisions, and its possible implication for patients' future health.

Inequalities in primary care management of knee pain and disability in older adults: an observational cohort study

OBJECTIVES

To describe primary care management of knee pain, in relation to National Institute for Health and Clinical Excellence (NICE) OA guidelines, and examine variation in management by patient characteristics.

METHODS

Subjects were 755 adults aged ≥50 years who responded to baseline and 3-year surveys and had consulted primary care for knee pain. Medical records (1997-2006) were searched. Associations of having interventions from the outer circle (adjunctive treatments or Step 3) of the NICE guidelines with self-reported socio-demographic and knee-specific factors were determined.

RESULTS

Eighty per cent had received a Step 3 intervention. Thirty-eight per cent had been referred to secondary care, and 10% had received a knee replacement. Forty-three per cent had been prescribed an opioid and 41% an NSAID. Severe knee pain or disability at baseline and follow-up was the main association with receiving a Step 3 intervention [adjusted odds ratio (OR) 2.26; 95% CI 1.38, 3.70] and with referral (OR 2.57; 95% CI 1.72, 3.83). Older patients were less likely to be referred. Although non-significant, those of higher social class, in more affluent areas, older age or overweight or obese, appeared more likely to receive a knee replacement. Fifty per cent of those reporting severe knee pain or disability in both surveys had not been referred to secondary care.

CONCLUSION

Most of the older adults who consult primary care with knee pain receive at least one Step 3 intervention from the OA guidelines. Inequalities in the management and referral of knee problems in primary care were generally not observed, although there were some trends towards differences in likelihood of total knee replacement.