Identifying patient decisions and related information needs during decision making related to total knee arthroplasty

Biopsychosocial Determinants for Total Knee Replacement Decisions Among Older Adults With Chronic Knee Osteoarthritis: A Scoping Review

Background: Total knee replacement (TKR) is a common surgical intervention for older adults with chronic knee osteoarthritis (KOA). Given the prevalence of comorbidities in this population, health priorities may vary, influencing decision-making regarding TKR. Despite the increasing number of TKRs, no scoping review has systematically examined the determinants shaping older adults' decisions using a biopsychosocial (BPS) model. Materials and Methods: Searches were undertaken in commercially produced and grey literature sources. Eligible studies included English-language qualitative and quantitative studies that investigated determinants influencing older adults' decision towards TKR. Two independent reviewers screened the results. The data were then independently extracted, which was then collated and synthesized, using the BPS model. Results: Out of 999 abstracts screened, 23 studies met the inclusion criteria. The included studies took place in Australia, Canada, Germany, Japan, Kuwait, Sweden, Taiwan, Turkey, the United Kingdom and the United States. Ten studies used qualitative study designs while thirteen used varying quantitative study designs. Under BPS model, these determinants were grouped into biological determinants: baseline physical health, disease severity, and pain symptoms; psychological determinants, including coping strategies, feelings of loss, mental stress, depression, and anxiety; and social determinants: support networks, financial resources, health insurance, and access to referral systems and surgery. Conclusion: The decision for TKR in older adults with chronic KOA is shaped by an intricate interplay of biological, psychological, and social factors. The most consistent determinants included the desire for pain relief and the ability to regain physical function. Religion and spirituality significantly influence stress and anxiety in older adults and transportation system also presents significant challenges for TKR surgery. A multifaceted strategy that improves the structures, processes, and outcomes of decision for TKR surgery is required among older adults with chronic KOA. Future research with large, representative samples and a focus on the BPS framework is needed to further explore this complex decision-making process.

Assessing patient information needs for new antidiabetic medications to inform shared decision-making: A best-worst scaling experiment in China

BACKGROUND

Shared decision-making (SDM) is a patient-centred approach to improve the quality of care. An essential requirement for the SDM process is to be fully aware of patient information needs.

OBJECTIVES

Our study aimed to assess patient information needs for new antidiabetic medications using the best-worst scaling (BWS) experiment.

METHODS

BWS tasks were developed according to a literature review and the focus group discussion. We used a balanced incomplete block design and blocking techniques to generate choice sets. The final BWS contains 11 attributes, with 6-choice scenarios in each block. The one-to-one, face-to-face BWS survey was conducted among type 2 diabetic patients in Jiangsu Province. Results were analyzed using count-based analysis and modelling approaches. We also conducted a subgroup analysis to observe preference heterogeneity.

RESULTS

Data from 539 patients were available for analysis. The most desired information domain was the comparative effectiveness of new antidiabetic medications. It consists of the incidence of macrovascular complications, the length of extended life years, changes in health-related quality of life, the incidence of microvascular complications, and the control of glycated haemoglobin. Of all the attributes, the incidence of macrovascular complications was the primary concern. Patients' glycemic control and whether they had diabetes complications exerted a significant influence on their information needs.

CONCLUSIONS

Information on health benefits is of critical significance for diabetic patients. Patients have different information needs as their disease progresses. Personalized patient decision aids that integrate patient information needs and provide evidence of new antidiabetic medications are worthy of being established.

PATIENT OR PUBLIC CONTRIBUTION

Before data collection, a pilot survey was carried out among diabetic patients to provide feedback on the acceptability and intelligibility of the attributes.

Development of a Machine Learning Model to Predict the Use of Surgery in Patients With Rheumatoid Arthritis

OBJECTIVE

One in five patients with rheumatoid arthritis (RA) rely on surgery to restore joint function. However, variable response to disease-modifying antirheumatic drugs (DMARDs) complicates surgical planning, and it is difficult to predict which patients may ultimately require surgery. We used machine learning to develop predictive models for the likelihood of undergoing an operation related to RA and which type of operation patients who require surgery undergo.

METHODS

We used electronic health record data to train two extreme gradient boosting machine learning models. The first model predicted patients' probabilities of undergoing surgery ≥5 years after their initial clinic visit. The second model predicted whether patients who underwent surgery would undergo a major joint replacement versus a less intensive procedure. Predictors included demographics, comorbidities, and medication data. The primary outcome was model discrimination, measured by area under the receiver operating characteristic curve (AUC).

RESULTS

We identified 5,481 patients, of whom 278 (5.1%) underwent surgery. There was no significant difference in the frequency of DMARD or steroid prescriptions between patients who did and did not have surgery, though nonsteroidal anti-inflammatory drug prescriptions were more common among patients who did have surgery (P = 0.03). The model predicting use of surgery had an AUC of 0.90 ± 0.02. The model predicting type of surgery had an AUC of 0.58 ± 0.10.

CONCLUSIONS

Predictive models using clinical data have the potential to facilitate identification of patients who may undergo rheumatoid-related surgery, but not what type of procedure they will need. Integrating similar models into practice has the potential to improve surgical planning.

Patient information pathway in orthopedic surgery: Roles of ERAS and pharmacists

INTRODUCTION

Enhanced Rehabilitation After Surgery (ERAS) pathways significantly improve the care of patients in orthopedic surgery. However, patient knowledge and memorization of the information provided are currently poorly documented.

HYPOTHESIS

The information provided by a postoperative pharmacist could have a positive impact on patient care, in particular by improving knowledge about their prosthesis.

MATERIAL AND METHOD

This prospective feasibility study included a cohort of 80 patients operated on for a hip or knee prosthesis and who received postoperative pharmacist interviews (POPI). These POPIs informed the patient about the prosthesis, the complications, positions to avoid, as well as the postoperative follow-up. The objective was to measure the patient's knowledge before and after the POPI. Qualitative and quantitative analyses, by indication and patient pathway, were performed.

RESULTS

The patient's knowledge before POPI was 70% correct. After POPI this rate rose to 91%.

DISCUSSION

Patients' knowledge was weak and heterogeneous, especially regarding the implanted prosthesis. The POPI led to significant improvement and standardization of knowledge which should contribute to the prevention of iatrogenic harm (positions to avoid, infection prevention, compliance with analgesics and anticoagulants).

CONCLUSION

A POPI with a pharmacist improves overall patient management during hip or knee arthroplasty.

LEVEL OF EVIDENCE

III; non-randomized prospective feasibility study.

Exploring appropriateness criteria for informing the total knee arthroplasty decision-making process: An interpretive descriptive study

RATIONAL

The Hawker appropriateness criteria for total knee arthroplasty (TKA) are: osteoarthritis symptoms impacting quality of life, evidence of osteoarthritis, trial of conservative treatments, patient's realistic expectations, patient/surgeon agree benefits outweigh risks, and readiness for surgery. Little is known about the barriers and facilitators of using the Hawker et al. appropriateness criteria for TKA in clinical practice.

AIMS AND OBJECTIVES

Explore the barriers and facilitators to using appropriateness criteria for TKA in making decisions for adults with knee osteoarthritis.

METHODS

Interpretive descriptive qualitative study at an academic hospital. Purposive sampling aimed to recruit: (1) healthcare team members at all levels influencing care delivery, and (2) adults with TKA assessed at the hospital clinic. Semi-structured interviews asked about the barriers/facilitators to using the Hawker appropriateness criteria. Data analysis consisted of inductive thematic analysis with themes mapped to the Consolidated Framework for Implementation Research domains.

RESULTS

Nine healthcare professionals and 14 adults with TKA participated and identified common barriers to using the Hawker appropriateness criteria: (a) intervention characteristics domain: difficulty to assess criteria, patients expecting healthcare professionals to decide, limited accessibility to conservative treatments; (b) individuals characteristics domain: no need to change current TKA process, clinical judgement limited to OA severity/age, implicit assessment of subjective criteria; (c) inner setting domain: TKA information received after decision made; and (d) outer setting domain: no timely access to TKA. A facilitator of use was evidence/buy-in fosters programme changes.

CONCLUSION

Barriers to using the criteria relevant to clinical practice and the healthcare system were identified while only one facilitator was revealed. Interventions tailored to these barriers are needed to support the use of the Hawker appropriateness criteria in TKA 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.

Patients' perspectives on the benefits of feedback on patient-reported outcome measures in a web-based personalized decision report for hip and knee osteoarthritis

BACKGROUND

Applications of patient-reported outcome measures (PROMs) for individual patient management are expanding with the support of digital tools. Providing PROM-based information to patients can potentially improve care experiences and outcomes through informing and activating patients. This study explored patients' perspectives on the benefits of receiving feedback on PROMs in the context of a web-based personalized decision report to guide care for their hip or knee osteoarthritis.

METHODS

This qualitative descriptive interview study was nested in a pragmatic clinical trial of a personalized report, which includes descriptive PROM scores and predicted postoperative PROM scores. Patients completed a semi-structured interview within 6 weeks of an office visit with an orthopaedic surgeon. Only patients who reported receiving the report and reviewing it with the surgeon and/or a health educator were included. Data were iteratively analyzed using a combination of deductive and inductive coding strategies.

RESULTS

Twenty-five patients aged 49-82 years (60% female, 72% surgical treatment decision) participated and described three primary benefits of the PROM feedback within the report: 1. Gaining Information About My Health Status, including data teaching new information, confirming what was known, or providing a frame of reference; 2. Fostering Communication Between Patient and Surgeon, encompassing use of the data to set expectations, ask and answer questions, and facilitate shared understanding; and 3. Increasing My Confidence and Trust, relating to the treatment outcomes, treatment decision, and surgeon.

CONCLUSIONS

Patients identified actual and hypothetical benefits of receiving feedback on PROM scores in the context of a web-based decision report, including advantages for those who had already made a treatment decision before seeing the surgeon. Findings provide insight into patients' perspectives on how digital PROM data can promote patient-centered care. Results should be considered in the context of the homogeneous sample and complex trial. While participants perceived value in this personalized report, questions remain regarding best practices in patient-facing data presentation and engagement.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03102580. Registered on 5 April 2017.