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Hamilton DF, Simpson PM, Patton JT, Howie CR, Burnett R. Aseptic Revision Knee Arthroplasty With Total Stabilizer Prostheses Achieves Similar Functional Outcomes to Primary Total Knee Arthroplasty at 2 Years: A Longitudinal Cohort Study. J Arthroplasty 2017; 32:1234-1240.e1. [PMID: 27916473 DOI: 10.1016/j.arth.2016.10.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patient function is poorly characterized following revision total knee arthroplasty (TKA), although is generally accepted to be inferior to that following primary procedures. METHODS Fifty-three consecutive aseptic revisions to total stabilizer devices were prospectively evaluated, preoperatively and at 6, 26, 52, and 104 weeks postoperatively, using the Oxford Knee Score (OKS), range of motion, pain rating scale, and timed functional performance battery. Data were assessed longitudinally and in comparison to primary TKA data with identical outcome assessments at equivalent time points. RESULTS Mean outcome changes were: 13 point increase in the OKS (from 17.5 [standard deviation-SD 7.4]-32.4 [SD 7.9] points); 21 degree improvement in the knee flexion (80.6 [SD 20.5]-101.5 [SD 13.2] degrees); 60% reduction in the pain report (7.7 [SD 2.3]-1.3 [SD 0.4] points); and 15 second improvement in the timed performance assessment (47.2 [SD 19.1]-32.0 [SD 7.0] seconds; P < .001). No difference was seen between primary and revision cohorts in OKS or pain scores (analysis of variance, P = .2 and .19). Knee flexion and timed performance assessment were different between primary and revision groups (analysis of variance, P = .03 and P = .02); however, this was due to differing preoperative values. The revision cohort achieved the same postoperative scores as the primary cohort at all postoperative time points. CONCLUSION Patients undergoing revision TKA for aseptic failure with total stabilizer implants made substantial improvements in the initial 2 years following surgery in both patient-reported and directly assessed function, comparable with that achieved following primary knee arthroplasty.
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Affiliation(s)
- David F Hamilton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip M Simpson
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, United Kingdom
| | - James T Patton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, United Kingdom
| | - Colin R Howie
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard Burnett
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, United Kingdom
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252
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Ashton F, Hamid K, Sulieman S, Eardley W, Baker P. Factors Influencing patient experience and satisfaction following surgical management of ankle fractures. Injury 2017; 48:960-965. [PMID: 28249677 DOI: 10.1016/j.injury.2017.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 02/21/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patient feedback is increasingly important to inform and develop effective healthcare within the United Kingdom. In order to optimise patient experience of ankle fracture care in our unit, we sought to identify elements of practice associated with poor patient experience and low levels of satisfaction. METHODS Adult patients with closed ankle fractures requiring fixation over a ten month period were prospectively identified. Prior to discharge all patients completed the Picker Patient Experience Questionnaire (PPE-15), satisfaction visual analogue scale (VAS: 0-10) and a demographic questionnaire. Operative delay and cancellation episodes were similarly noted. PPE-15 and satisfaction VAS data were collected concurrently from a control group of elective hip and knee arthroplasty patients. RESULTS 52 patients (23 males) of average age 47 years (17-86) underwent ankle fracture fixation. Median pre-operative length of stay (LOS) was 3days (IQR 1-6). Ankle fracture patients had significantly worse experiences compared to arthroplasty patients (p<0.05 across all 15 PPE domains). Once pre-operative length of stay exceeded 3days patients reported more areas of concerns (6 of 15) than those waiting 3days or less (4 of 15) (p=0.02). Cancelled patients reported significantly worse experiences, with satisfaction VAS of 7 (versus 9 in those not cancelled [p=0.005]), and median of 6 PPE-15 domains of concern (versus 3.5 [p=0.03]). CONCLUSIONS Efforts to improve the healthcare experience of patients with ankle fractures should be focused on improving processes that minimise cancellation of surgery and the communication around delay management.
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Affiliation(s)
- Fiona Ashton
- Department of Trauma & Orthopaedics, South Tees NHS Trust, UK
| | - Khalid Hamid
- Department of Trauma & Orthopaedics, South Tees NHS Trust, UK
| | | | - William Eardley
- Department of Trauma & Orthopaedics, South Tees NHS Trust, UK
| | - Paul Baker
- Department of Trauma & Orthopaedics, South Tees NHS Trust, UK.
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253
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Goldsmith LJ, Suryaprakash N, Randall E, Shum J, MacDonald V, Sawatzky R, Hejazi S, Davis JC, McAllister P, Bryan S. The importance of informational, clinical and personal support in patient experience with total knee replacement: a qualitative investigation. BMC Musculoskelet Disord 2017; 18:127. [PMID: 28340610 PMCID: PMC5366158 DOI: 10.1186/s12891-017-1474-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/06/2017] [Indexed: 01/17/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is the most frequently performed joint replacement surgery in North America. Patient perspectives on TKA have been investigated in various ways, including finding as many as 20% of TKA patients are dissatisfied with their surgical outcomes. Understanding the patient experience with TKA broadly and in relation to patient satisfaction is a key gap in existing literature. Methods We report on the qualitative component of a mixed methods prospective cohort study examining patient experience and satisfaction post-TKA for adults in British Columbia, Canada. Data collection consisted of 45 in-depth interviews about individuals’ knee surgery experiences conducted eight months after surgery. Analysis consisted of thematic coding by multiple coders. Results Participants’ descriptions of their TKA experiences were primarily concerned with support, or the provision of aid and assistance. Support was insufficient when their expectations of support were not met; unmet support expectations led to an overall negative TKA experience. Support operated in three key domains: (1) informational support, (2) clinical support, and (3) personal support. Key sources of informational and clinical support included pre-optimisation clinics, surgeons, and physiotherapists. Key topics for informational support included pain, pain management, and recovery trajectories. Personal support was provided by family, friends, other TKA patients, employers, and themselves. Conclusions Patient needs and expectations for support are shaped both before and after TKA surgery. Patients with an overall positive TKA experience had improvement in their knee pain, stiffness or functioning post-TKA, had their major expectations and needs for support met during their TKA recovery, and believed that any significant future expectations or needs for ongoing support would be adequately met. In contrast, patients with an overall negative TKA experience had at least one major expectation or need for support not met during their TKA recovery, even in cases where they had good TKA outcomes. Suggested interventions to improve the experience of persons receiving TKA include an expanded patient navigator model, revised pre-surgery educational materials, particularly around pain expectations and management, and comprehensive sharing of other patients’ TKA experience.
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Affiliation(s)
- Laurie J Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall 10506, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
| | - Nitya Suryaprakash
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Ellen Randall
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jessica Shum
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Department of Experimental Medicine, Faculty of Medicine, University of British Columbia, 10th Floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Valerie MacDonald
- Burnaby Hospital & Surgical Network, Fraser Health, 3935 Kincaid Street, Burnaby, BC, V5K 2X6, Canada
| | - Richard Sawatzky
- School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BC, V2Y 1Y1, Canada.,Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, St. Paul's Hospital, 588-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Samar Hejazi
- Department of Evaluation and Research Service, Fraser Health, Suite 400, Central City Tower, 13450 102 Avenue, Surrey, BC, V3T 0H1, Canada
| | - Jennifer C Davis
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.,Aging, Mobility, and Cognitive Neurosciences Lab, University of British Columbia, Djavad Mowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | | | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.,School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
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254
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Newman M, Barker K. Rehabilitation of revision total hip replacement: A multi-centre survey of current practice. Musculoskeletal Care 2017; 15:386-394. [PMID: 28317236 DOI: 10.1002/msc.1187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Demand for revision total hip replacement (RTHR) is increasing. Outcomes after RTHR are varied, with reasonable pain relief but smaller gains in function and mobility. Whether sub-optimal rehabilitation contributes to poorer functional outcomes is unclear. Current rehabilitation is not well defined and there is little research into RTHR rehabilitation. AIMS AND OBJECTIVES To gather information about the current rehabilitation of patients undergoing planned, single-stage revision or re-revision THR surgery. METHODS An online survey was developed and sent to clinicians at 117 orthopaedic centres in England, Wales and Northern Ireland. Questions were asked about standard rehabilitation practice pre-operatively, post-operatively and immediately after discharge. The frequency (%) of responses to closed questions was analysed and free-text comments were summarized thematically. RESULTS There were 133 respondents: mostly physiotherapists (92, 69%) and occupational therapists (39, 29%). Pre-operative education was common (112, 84%) but not uniform, and for 52 (46%) the same as for primary THR patients. Respondents were more likely to agree about the general objectives of rehabilitation, for example gait re-education with walking aids (93, 70%), and retraining functional mobility (92, 69%) rather than about specific elements including exercise prescription, duration of hip precautions and provision of occupational therapy. The provision of rehabilitation following discharge varied considerably. CONCLUSIONS This survey adds to sparse information about rehabilitation RTHR. No consensus emerged about optimal rehabilitation. The diversity in approach and lack of clear structure suggests work is needed to develop rehabilitation interventions that are tailored to this population.
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Affiliation(s)
- Meredith Newman
- Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Karen Barker
- Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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255
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Hussain MS, Li J, Brindal E, van Kasteren Y, Varnfield M, Reeson A, Berkovsky S, Freyne J. Supporting the Delivery of Total Knee Replacements Care for Both Patients and Their Clinicians With a Mobile App and Web-Based Tool: Randomized Controlled Trial Protocol. JMIR Res Protoc 2017; 6:e32. [PMID: 28249832 PMCID: PMC5352858 DOI: 10.2196/resprot.6498] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/21/2016] [Accepted: 02/08/2017] [Indexed: 01/25/2023] Open
Abstract
Background Total knee replacement (TKR) surgeries have increased in recent years. Exercise programs and other interventions following surgery can facilitate the recovery process. With limited clinician contact time, patients with TKR have a substantial burden of self-management and limited communication with their care team, thus often fail to implement an effective rehabilitation plan. Objective We have developed a digital orthopedic rehabilitation platform that comprises a mobile phone app, wearable activity tracker, and clinical Web portal in order to engage patients with self-management tasks for surgical preparation and recovery, thus addressing the challenges of adherence to and completion of TKR rehabilitation. The study will determine the efficacy of the TKR platform in delivering information and assistance to patients in their preparation and recovery from TKR surgery and a Web portal for clinician care teams (ie, surgeons and physiotherapists) to remotely support and monitor patient progress. Methods The study will evaluate the TKR platform through a randomized controlled trial conducted at multiple sites (N=5) in a number of states in Australia with 320 patients undergoing TKR surgery; the trial will run for 13 months for each patient. Participants will be randomized to either a control group or an intervention group, both receiving usual care as provided by their hospital. The intervention group will receive the app and wearable activity tracker. Participants will be assessed at 4 different time points: 4 weeks before surgery, immediately before surgery, 12 weeks after surgery, and 52 weeks after surgery. The primary outcome measure is the Oxford Knee Score. Secondary outcome measures include quality of life (Short-Form Health Survey); depression, anxiety, and stress (Depression, Anxiety, and Stress Scales); self-motivation; self-determination; self-efficacy; and the level of satisfaction with the knee surgery and care delivery. The study will also collect quantitative usage data related to all components (app, activity tracker, and Web portal) of the TKR platform and qualitative data on the perceptions of the platform as a tool for patients, carers, and clinicians. Finally, an economic evaluation of the impact of the platform will be conducted. Results Development of the TKR platform has been completed and deployed for trial. The research protocol is approved by 2 human research ethics committees in Australia. A total of 5 hospitals in Australia (2 in New South Wales, 2 in Queensland, and 1 in South Australia) are expected to participate in the trial. Conclusions The TKR platform is designed to provide flexibility in care delivery and increased engagement with rehabilitation services. This trial will investigate the clinical and behavioral efficacy of the app and impact of the TKR platform in terms of service satisfaction, acceptance, and economic benefits of the provision of digital services. Trial Registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12616000504415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370536 (Archived by WebCite at http://www.webcitation.org/6oKES0Gp1)
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Affiliation(s)
- M Sazzad Hussain
- Health and Biosecurity, Commonwealth Scientific and Industrial Research Organization, Epping, NSW, Australia
| | - Jane Li
- Health and Biosecurity, Commonwealth Scientific and Industrial Research Organization, Epping, NSW, Australia
| | - Emily Brindal
- Health and Biosecurity, Commonwealth Scientific and Industrial Research Organization, Adelaide, SA, Australia
| | - Yasmin van Kasteren
- Flinders Digital Health Research Centre, Flinders University, Adelaide, SA, Australia
| | - Marlien Varnfield
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organization, Herston, QLD, Australia
| | - Andrew Reeson
- Data61, Commonwealth Scientific and Industrial Research Organization, Acton, ACT, Australia
| | - Shlomo Berkovsky
- Data61, Commonwealth Scientific and Industrial Research Organization, Sydney, NSW, Australia
| | - Jill Freyne
- Health and Biosecurity, Commonwealth Scientific and Industrial Research Organization, Epping, NSW, Australia
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256
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Scott CEH, Oliver WM, MacDonald D, Wade FA, Moran M, Breusch SJ. Predicting dissatisfaction following total knee arthroplasty in patients under 55 years of age. Bone Joint J 2017; 98-B:1625-1634. [PMID: 27909124 DOI: 10.1302/0301-620x.98b12.bjj-2016-0375.r1] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 08/22/2016] [Indexed: 11/05/2022]
Abstract
AIMS Risk of revision following total knee arthroplasty (TKA) is higher in patients under 55 years, but little data are reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction in these patients. PATIENTS AND METHODS We prospectively assessed 177 TKAs (157 consecutive patients, 99 women, mean age 50 years; 17 to 54) from 2008 to 2013. Age, gender, implant, indication, body mass index (BMI), social deprivation, range of movement, Kellgren-Lawrence (KL) grade of osteoarthritis (OA) and prior knee surgery were recorded. Pre- and post-operative Oxford Knee Score (OKS) as well as Short Form-12 physical (PCS) and mental component scores were obtained. Post-operative range of movement, complications and satisfaction were measured at one year. RESULTS Overall, 44 patients with 44 TKAs (24.9%) under 55 years of age were unsure or dissatisfied with their knee. Significant predictors of dissatisfaction on univariate analysis included: KL grade 1/2 OA (59% dissatisfied), poor pre-operative OKS, complications, poor improvements in PCS and OKS and indication (primary OA 19% dissatisfied, previous meniscectomy 41%, multiply operated 42%, other surgery 29%, BMI > 40 kg/m2 31%, post-traumatic OA 45%, and inflammatory arthropathy 5%). Poor pre-operative OKS, poor improvement in OKS and post-operative stiffness independently predicted dissatisfaction on multivariate analysis. CONCLUSION Patients receiving TKA younger than 55 years old should be informed about the increased risks of dissatisfaction. Offering TKA in KL 1/2 is questionable, with a dissatisfaction rate of 59%. Cite this article: Bone Joint J 2016;98-B:1625-34.
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Affiliation(s)
- C E H Scott
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - W M Oliver
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D MacDonald
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - F A Wade
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - M Moran
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - S J Breusch
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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257
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Fletcher D, Edwards D, Tolchard S, Baker R, Berstock J. Improving theatre turnaround time. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjquality_uu219831.w8131. [PMID: 28243441 PMCID: PMC5306684 DOI: 10.1136/bmjquality.u219831.w8131] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/31/2017] [Indexed: 11/26/2022]
Abstract
The NHS Institute for Innovation and Improvement has determined that a £7 million saving can be achieved per trust by improving theatre efficiency. The aim of this quality improvement project was to improve orthopaedic theatre turnaround without compromising the patient safety. We process mapped all the stages from application of dressing to knife to skin on the next patient in order to identify potential areas for improvement. Several suggestions arose which were tested in multiple PDSA cycles in a single theatre. These changes were either adopted, adapted or rejected on the basis of run chart data and theatre team feedback. Successful ideas which were adopted included, the operating department practitioner (ODP) seeing and completing check-in paperwork during the previous case rather than during turnaround, a 15 minute telephone warning to ensure the next patient was fully ready, a dedicated cleaning team mobilised during wound closure, sending for the next patient as theatre cleaning begins. Run charts demonstrate that as a result of these interventions the mean turnaround time almost halved from 66.5 minutes in July to 36.8 minutes over all PDSA cycles. This improvement has been sustained and rolled out into another theatre. As these improvements become more established we hope that additional cases will be booked, improving theatre output. The PDSA cycle continues as we believe that further gains may yet be made, and our improvements may be rolled out across other surgical specialities.
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258
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Hamilton DF, Loth FL, Giesinger JM, Giesinger K, MacDonald DJ, Patton JT, Simpson AHRW, Howie CR. Validation of the English language Forgotten Joint Score-12 as an outcome measure for total hip and knee arthroplasty in a British population. Bone Joint J 2017; 99-B:218-224. [DOI: 10.1302/0301-620x.99b2.bjj-2016-0606.r1] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 10/13/2016] [Indexed: 11/05/2022]
Abstract
Aims To validate the English language Forgotten Joint Score-12 (FJS-12) as a tool to evaluate the outcome of hip and knee arthroplasty in a United Kingdom population. Patients and Methods All patients undergoing surgery between January and August 2014 were eligible for inclusion. Prospective data were collected from 205 patients undergoing total hip arthroplasty (THA) and 231 patients undergoing total knee arthroplasty (TKA). Outcomes were assessed with the FJS-12 and the Oxford Hip and Knee Scores (OHS, OKS) pre-operatively, then at six and 12 months post-operatively. Internal consistency, convergent validity, effect size, relative validity and ceiling effects were determined. Results Data for the TKA and THA patients showed high internal consistency for the FJS-12 (Cronbach α = 0.97 in TKAs, 0.98 in THAs). Convergent validity with the Oxford Scores was high (r = 0.85 in TKAs, r = 0.79 for THAs). From six to 12 months, the change was higher for the FJS-12 than for the OHS in THA patients (effect size d = 0.21 versus -0.03). Ceiling effects at one-year follow-up were low for the FJS-12 with just 3.9% (TKA) and 8.8% (THA) of patients achieving the best possible score. Conclusion The FJS-12 has strong measurement properties in terms of validity, internal consistency and sensitivity to change in TKA and THA patients. Low ceiling effects and good relative validity allow the monitoring of longer term outcomes, particularly in well-performing groups after total joint arthroplasty. Cite this article: Bone Joint J 2017;99-B:218–24.
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Affiliation(s)
| | - F. L. Loth
- Medical University of Innsbruck, Innsbruck, Austria
| | | | - K. Giesinger
- Kantonsspital St. Gallen, St
Gallen, Switzerland
| | | | | | - A. H. R. W. Simpson
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
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259
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Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop 2016; 87:615-621. [PMID: 27622598 PMCID: PMC5119445 DOI: 10.1080/17453674.2016.1228411] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients' expectations of outcomes following arthroscopic meniscus surgery are largely unknown. We investigated patients' expectations concerning recovery and participation in leisure-time activities after arthroscopic meniscus surgery and the postoperative fulfillment of these. Patients and methods - The study sample consisted of 491 consecutively recruited patients (mean age 50 (SD 13) years, 55% men) who were assigned for arthroscopy on suspicion of meniscus injury and later verified by arthroscopy. Before surgery, patients completed questionnaires regarding their expectations of recovery time and postoperative participation in leisure activities. 3 months after surgery, the patients completed questionnaires on their actual level of leisure activity and their degree of satisfaction with their current knee function. We analyzed differences between the expected outcome and the actual outcome, and between fulfilled/exceeded expectations and satisfaction with knee function. Results - 478 patients (97%) completed the follow-up. 91% had expected to be fully recovered within 3 months. We found differences between patients' preoperative expectations of participation in leisure activities postoperatively and their actual participation in these, with 59% having unfulfilled expectations (p < 0.001). Satisfaction with current knee function was associated with expectations of leisure activities being fulfilled/exceeded. Interpretation - In general, patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations of recovery time and regarding participation in leisure-time activities after meniscal surgery.
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Affiliation(s)
- Kenneth Pihl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense;,Department of Physiotherapy, Zealand University Hospital, Køge;,Correspondence:
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense
| | - Nis Nissen
- Department of Orthopedics, Lillebaelt Hospital, Kolding
| | - Uffe JøRgensen
- Department of Orthopedics and Traumatology, Odense University Hospital, Odense
| | | | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense
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260
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Reid R, Puvanesarajah V, Kandil A, Yildirim B, Shimer AL, Singla A, Shen FH, Hassanzadeh H. Factors Associated with Patient-Initiated Telephone Calls After Spine Surgery. World Neurosurg 2016; 98:625-631. [PMID: 27838431 DOI: 10.1016/j.wneu.2016.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Telephone calls play a significant role in the follow-up care of postoperative patients. However, further data are needed to identify the determinants of patient-initiated telephone calls after surgery because these factors may also highlight potential areas of improvement in patient satisfaction and during the hospital discharge process. Therefore, the goal of this study is to determine the number of postoperative patient telephone calls within 14 days after surgery and establish the factors associated with patient-initiated calls and reasons for calling. METHODS A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014, through January 2, 2015, was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls. RESULTS Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. There were 61 patients (27.48%) who called regarding pain control and 54 patients (23.87%) who called with bathing/dressing/wound questions. Other common categories include the following: other (21.17%), medication problems (15.77%), weight-bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased body mass index (P = 0.031), lower number of comorbidities (P = 0.043), telephone call within 2 weeks prior to surgery (P = 0.027), American Society of Anesthesiologists (ASA) score of 2 (P = 0.036), discharge disposition to home (P = 0.003), and elective procedure (P = 0.006). Multivariate analysis revealed that fusion procedures (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.05-4.45; P = 0.037) and ASA score of 3-4 (OR, 0.55; 95% CI, 0.31-0.96, P = 0.036) were independently associated with increased and decreased propensity, respectively, toward making a phone call within 2 weeks. CONCLUSIONS Postoperative patient-initiated telephone calls within 14 days after spine surgery are very common, occurring after almost one half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.
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Affiliation(s)
- Risa Reid
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Abdurrahman Kandil
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Baris Yildirim
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Adam L Shimer
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Anuj Singla
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Francis H Shen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Rolfson O, Wissig S, van Maasakkers L, Stowell C, Ackerman I, Ayers D, Barber T, Benzakour T, Bozic K, Budhiparama N, Caillouette J, Conaghan PG, Dahlberg L, Dunn J, Grady-Benson J, Ibrahim SA, Lewis S, Malchau H, Manzary M, March L, Nassif N, Nelissen R, Smith N, Franklin PD. Defining an International Standard Set of Outcome Measures for Patients With Hip or Knee Osteoarthritis: Consensus of the International Consortium for Health Outcomes Measurement Hip and Knee Osteoarthritis Working Group. Arthritis Care Res (Hoboken) 2016; 68:1631-1639. [PMID: 26881821 PMCID: PMC5129496 DOI: 10.1002/acr.22868] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/20/2016] [Accepted: 02/09/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To define a minimum Standard Set of outcome measures and case-mix factors for monitoring, comparing, and improving health care for patients with clinically diagnosed hip or knee osteoarthritis (OA), with a focus on defining the outcomes that matter most to patients. METHODS An international working group of patients, arthroplasty register experts, orthopedic surgeons, primary care physicians, rheumatologists, and physiotherapists representing 10 countries was assembled to review existing literature and practices for assessing outcomes of pharmacologic and nonpharmacologic OA therapies, including surgery. A series of 8 teleconferences, incorporating a modified Delphi process, were held to reach consensus. RESULTS The working group reached consensus on a concise set of outcome measures to evaluate patients' joint pain, physical functioning, health-related quality of life, work status, mortality, reoperations, readmissions, and overall satisfaction with treatment result. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were defined. Annual outcome measurement is recommended for all patients. CONCLUSION We have defined a Standard Set of outcome measures for monitoring the care of people with clinically diagnosed hip or knee OA that is appropriate for use across all treatment and care settings. We believe this Standard Set provides meaningful, comparable, and easy to interpret measures ready to implement in clinics and/or registries globally. We view this set as an initial step that, when combined with cost data, will facilitate value-based health care improvements in the treatment of hip and knee OA.
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Affiliation(s)
- Ola Rolfson
- International Consortium for Health Outcomes Measurement, Cambridge, Massachusetts, Harris Orthopaedic Laboratory, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Stephanie Wissig
- International Consortium for Health Outcomes Measurement, Cambridge, Massachusetts
| | - Lisa van Maasakkers
- International Consortium for Health Outcomes Measurement, Cambridge, Massachusetts
| | - Caleb Stowell
- International Consortium for Health Outcomes Measurement, Cambridge, Massachusetts
| | | | - David Ayers
- University of Massachusetts Medical School, Worchester
| | | | | | - Kevin Bozic
- Dell Medical School, University of Texas at Austin
| | - Nicolaas Budhiparama
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jakarta, Indonesia
| | | | - Philip G Conaghan
- University of Leeds and National Institute for Health Research Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | | | | | | | - Said A Ibrahim
- University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sally Lewis
- Aneurin Bevan Health Board, Newport, Wales, UK
| | - Henrik Malchau
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, and Harris Orthopaedic Laboratory, Massachusetts General Hospital, and Harvard Medical School, Boston
| | - Mojieb Manzary
- The Johns Hopkins Aramco Health Care Center, Dhahran, Saudi Arabia
| | - Lyn March
- North Sydney Orthopaedic and Sports Medicine Centre and University of Sydney Institute of Bone and Joint, Royal North Shore Hospital, North Sydney, New South Wales, Australia
| | - Nader Nassif
- Hoag Orthopedic Institute, Newport Beach, California
| | | | - Noel Smith
- Arthritis Victoria, Elsternwick, Victoria, Australia
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Ingale H, Muquit S, Al-Helli O, White B, Basu S. The Nottingham Expectation and Complication score following Surgery (NECS): an universal scale for surgical outcome audit and peer comparison. Br J Neurosurg 2016; 31:237-243. [PMID: 27760477 DOI: 10.1080/02688697.2016.1244251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Consultant Outcomes Publication (COP) is an NHS England initiative for promoting improvements in quality of care. However, at present outcomes are commonly expressed as mortality rates which do not necessarily reflect the performance of surgeons. We developed the Nottingham Expectation and Complication score following Surgery (NECS) to determine the success of surgical treatment from both the clinical perspective and the practical expectations agreed between surgeons and patients during the consent process. METHOD This was a pilot study to trial the use of the NECS score. It is a simple expression of overall outcome comprising three clinical domains: S - surgical outcome, T - surgical/technical complications and M - medical complications recorded by the treating clinician, and practical outcome determined by a joint clinical/patient assessment. 107 elective neurosurgical patients were included in this prospective study. 95 completed questionnaires were included. RESULTS 75% patients achieved the best possible treatment score (S3T3M4). Of the 25% of patients who did not achieve this ideal outcome, the most common cause was either medical deterioration 18%, or technical complications of surgery discussed during the consent process 17%, or both. Surgeons rated their outcomes as expectations exceeded in 2% of cases, met in 92%, partially met in 5% and failed in 1%. Patients rated their outcomes as expectations exceeded in 37%, met in 37%, partially met in 18%, and 5% reported that their expectations were not met or they were worse than before the operation. Bivariate correlation analysis (Pearson's r coefficient) between overall 'expectation score' of patients and surgeons showed moderate correlation with r = .25 (p = .014). CONCLUSION NECS score can be used as an indicator to assess technical performance and patient satisfaction. It provides a more balanced quality indicator of the surgical service delivery than COP. It also offers additional advantages for auditing/planning improving care and may serve as an appraisal/revalidation tool.
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Affiliation(s)
- Harshal Ingale
- a Department of Neurosurgery , Queens Medical Centre, Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - Samiul Muquit
- a Department of Neurosurgery , Queens Medical Centre, Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - Othman Al-Helli
- a Department of Neurosurgery , Queens Medical Centre, Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - Barrie White
- a Department of Neurosurgery , Queens Medical Centre, Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - Surajit Basu
- a Department of Neurosurgery , Queens Medical Centre, Nottingham University Hospitals NHS Trust , Nottingham , UK
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Pezold ML, Pusic AL, Cohen WA, Hollenberg JP, Butt Z, Flum DR, Temple LK. Defining a Research Agenda for Patient-Reported Outcomes in Surgery: Using a Delphi Survey of Stakeholders. JAMA Surg 2016; 151:930-936. [PMID: 27437666 PMCID: PMC5216456 DOI: 10.1001/jamasurg.2016.1640] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Identifying timely and important research questions using relevant patient-reported outcomes (PROs) in surgery remains paramount in the current medical climate. The inaugural Patient-Reported Outcomes in Surgery (PROS) Conference brought together stakeholders in PROs research in surgery with the aim of creating a research agenda to help determine future directions and advance cross-disciplinary collaboration. Objective To create a research agenda to help determine future directions and advance cross-disciplinary collaboration on the use of PROs in surgery. Design, Setting, and Participants An iterative web-based interface was used to create a conference-based, modified Delphi survey for registrants at the PROS Conference (January 29-30, 2015), including surgeons, PRO researchers, payers, and other stakeholders. In round 1, research items were generated from qualitative review of responses to open-ended prompts. In round 2, items were ranked using a 5-point Likert scale; attendees were also asked to submit any new items. In round 3, the top 30 items and newly submitted items were redistributed for final ranking using a 3-point Likert scale. The top 20 items by mean rating were selected for the research agenda. Main Outcomes and Measures An expert-generated research agenda on PROs in surgery. Results Of the 143 people registered for the conference, 137 provided valid email addresses. There was a wide range of attendees, with the 3 most common groups being plastic surgeons (28 [19.6%]), general surgeons (19 [13.3%]), and researchers (25 [17.5%]). In round 1, participants submitted 459 items, which were reduced through qualitative review to 53 distinct items across 7 themes of PROs research. A research agenda was formulated after 2 successive rounds of ranking. The research agenda identified 3 themes important for future PROs research in surgery: (1) PROs in the decision-making process, (2) integrating PROs into the electronic health record, and (3) measuring quality in surgery with PROs. Conclusions and Relevance The PROS Conference research agenda was created using a modified Delphi survey of stakeholders that will help researchers, surgeons, and funders identify crucial areas of future PROs research in surgery.
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Affiliation(s)
- Michael L. Pezold
- Department of Surgery, Weill Cornell Medical Center-New York Presbyterian Hospital, New York, NY
| | - Andrea L. Pusic
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Wess A. Cohen
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Zeeshan Butt
- Departments of Medical Social Sciences, Surgery, & Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Larissa K. Temple
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Kirkness CS, Asche CV, Ren J, Gordon K, Maurer P, Maurer B, Maurer BT. Assessment of liposome bupivacaine infiltration versus continuous femoral nerve block for postsurgical analgesia following total knee arthroplasty: a retrospective cohort study. Curr Med Res Opin 2016; 32:1727-1733. [PMID: 27326760 DOI: 10.1080/03007995.2016.1205007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Perioperative pain management is an important aspect of recovery from total knee arthroplasty (TKA) because severe pain can delay ambulation and hospital discharge. The objective of this retrospective sequential cohort study was to determine the impact of local infiltration analgesia using liposome bupivacaine (Exparel 1 ) when compared with a continuous femoral nerve block (FNB) following TKA. METHODS This retrospective cohort study included consecutive patients who underwent TKA between April 2011 and April 2014, and received one of three interventions. Study Group A received adductor canal infiltration with bupivacaine HCl and knee infiltration with liposome bupivacaine. Study Group B received adductor canal infiltration with liposome bupivacaine and knee infiltration with liposome bupivacaine. The control group received a continuous FNB with ropivacaine HCl delivered via an elastomeric pump. Numeric pain rating scores (NPRS), distance walked, length of stay (LOS), and dose of narcotic medication were the key efficacy variables of interest. RESULTS A total of 237 patients were included in this study: 98 in Group A, 34 in Group B, and 105 controls. On postoperative day (POD) 0, mean (standard deviation [SD]) NPRSs were similar between Group A (1.8 [1.7]), Group B (2.7 [1.8]), and the control group (2.3 [2.4]). Significantly (p < 0.05) more patients in Group A (58%) and Group B (44%) walked on POD0 than in the control group (0%); almost all patients walked on POD1. The mean (SD) distance walked was also significantly greater (p < 0.05) on POD1 in Group A (193 [203] feet) and Group B (211 [144] feet) than in the control group (46 [73] feet). Mean (SD) LOS was significantly (p < 0.05) shorter in Group B (2.2 [1.2] days), than in the control group (3.2 [0.7] days) and Group A (3.0 [1.7] days). CONCLUSIONS Local infiltration analgesia using liposome bupivacaine was associated with improved ambulation and shorter LOS following TKA when compared with continuous FNB in this retrospective cohort study.
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Affiliation(s)
- C S Kirkness
- a Department of Medicine , University of Illinois College of Medicine at Peoria , Peoria , IL , USA
| | - C V Asche
- b Center for Outcomes Research, University of Illinois College of Medicine , Peoria , IL , USA
- c Department of Pharmacy Systems, Outcomes & Policy , University of Illinois at Chicago College of Pharmacy , Chicago , IL , USA
| | - J Ren
- d University of Illinois College of Medicine , Peoria , IL , USA
| | - K Gordon
- e UnityPoint Health-Proctor Hospital , Peoria , IL , USA
| | - P Maurer
- b Center for Outcomes Research, University of Illinois College of Medicine , Peoria , IL , USA
| | - B Maurer
- b Center for Outcomes Research, University of Illinois College of Medicine , Peoria , IL , USA
| | - B T Maurer
- f Great Plains Orthopedic , Peoria , IL , USA
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Tyser AR, Abtahi AM, McFadden M, Presson AP. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res 2016; 16:350. [PMID: 27488567 PMCID: PMC4972948 DOI: 10.1186/s12913-016-1595-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/28/2016] [Indexed: 12/30/2022] Open
Abstract
Background Measures of patient satisfaction have gained prominence in recent years as changes to the American health care system have led to the incorporation of such metrics into reimbursement models. The response rate for widely-used outpatient satisfaction metrics and variables influencing the probability of survey nonresponse remain largely unknown. Methods We reviewed all unique adult patients (16,779) who completed an outpatient encounter in the Department of Orthopaedic surgery at our academic institution from 1/1/13 to 10/24/13. Survey data was linked to each clinic visit, and patient factors including age, sex, insurance type, zip code, and orthopaedic subspecialty visited were recorded. The overall survey response rate was calculated. Logistic regression was performed, and unadjusted and adjusted odds ratios of patients’ probability of responding to the Press-Ganey survey were calculated. Results Two thousand seven hundred sixty two (16.5 %) of individuals completed a Press-Ganey patient satisfaction survey and 14017 patients did not respond. For those patients considered responders, 906 patients (32.8 %) did not complete all the survey items. Among these 906 patients, the mean number of missing items was 2.24 (Standard Deviation SD: 2.19). Age, sex, insurance type, and orthopaedic subspecialty were all found to be associated with the odds of responding to our patient satisfaction survey. Advancing age increased the odds of responding to the survey (Adjusted Odds Ratio (OR) = 3.396 for ≥65 vs. 18–29, p < 0.001). Several variables were associated with a decreased odds of survey response, and included male sex (Adjusted OR = 0.782 for Males vs. Females, p < 0.001), insurance type (Adjusted OR = 0.311 for Medicaid/Self-Pay vs. Private), and subspecialty type (Adjusted OR = 0.623 for Trauma vs. Adult Reconstruction). Conclusions The response rate to the Press-Ganey Medical Practice Survey of outpatient satisfaction is low in an orthopaedic outpatient population, and furthermore, is impacted by patient characteristics such as age, sex, insurance type, and type of orthopaedic subspecialist encountered. The findings of the present study should inform future non-response weighting procedures in this area. More research is needed to assess non-response bias—including follow-up studies of non-respondents—in order to more accurately measure of patient satisfaction.
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Affiliation(s)
- A R Tyser
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - A M Abtahi
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - M McFadden
- Department of Internal Medicine, Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - A P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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Is Satisfaction with the Acute-Care Experience Higher amongst Consumers Treated in the Private Sector? A Survey of Public and Private Sector Arthroplasty Recipients. PLoS One 2016; 11:e0159799. [PMID: 27490358 PMCID: PMC4973896 DOI: 10.1371/journal.pone.0159799] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 07/08/2016] [Indexed: 12/02/2022] Open
Abstract
Background Consumer satisfaction with the acute-care experience could reasonably be expected to be higher amongst those treated in the private sector compared to those treated in the public sector given the former relies on high-level satisfaction of its consumers and their subsequent recommendations to thrive. The primary aims of this study were to determine, in a knee or hip arthroplasty cohort, if surgery in the private sector predicts greater overall satisfaction with the acute-care experience and greater likelihood to recommend the same hospital. A secondary aim was to determine whether satisfaction across a range of service domains is also higher in the private sector. Methods A telephone survey was conducted 35 days post-surgery. The hospital cohort comprised eight public and seven private high-volume arthroplasty providers. Consumers rated overall satisfaction with care out of 100 and likeliness to recommend their hospital on a 5-point Likert scale. Additional Likert-style questions were asked covering specific service domains. Generalized estimating equation models were used to analyse overall satisfaction (dichotomised as ≥ 90 or < 90) and future recommendations for care (dichotomised as ‘definitely recommend’ or ‘other’), whilst controlling for covariates. The proportions of consumers in each sector reporting the best Likert response for each individual domain were compared using non-parametric tests. Results 457 survey respondents (n = 210 private) were included. Less patient-reported joint impairment pre-surgery [OR 1.03 (95% CI 1.01–1.05)] and absence of an acute complication (OR 2.13 95% CI 1.41–3.23) significantly predicted higher overall satisfaction. Hip arthroplasty [OR 1.84 (1.1–2.96)] and an absence of an acute complication [OR 2.31 (1.28–4.17] significantly predicted greater likelihood for recommending the hospital. The only care domains where the private out-performed the public sector were hospitality (46.7 vs 35.6%, p <0.01) and frequency of surgeon visitation (76.4 vs 65.8%, p = 0.03). Conclusions Arthroplasty consumers treated in the private sector are not more satisfied with their acute-care experience nor are they more likely to recommend their hospital provider. Rather, avoidance of complications in either sector appears to result in improved satisfaction as well as a greater likelihood that patients would recommend their hospital provider.
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Satisfaction With the Outcome of Physical Therapist-Prescribed Exercise in Chronic Whiplash-Associated Disorders: Secondary Analysis of a Randomized Clinical Trial. J Orthop Sports Phys Ther 2016; 46:640-9. [PMID: 27374016 DOI: 10.2519/jospt.2016.6136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Secondary analysis of a randomized clinical trial. Background Patient perception of the benefits gained from treatment is important, yet satisfaction with the outcome of treatment for chronic whiplash-associated disorders (WADs) has not been investigated. Objectives To investigate whether satisfaction with the outcome of treatment for chronic WAD changed over time, and whether there were group differences. Methods Two hundred sixteen people with chronic WAD (66% women; mean age, 40.4 years) participated in a 3-month program of physical therapist-led neck-specific exercises with or without a behavioral approach, or received a prescription of general physical activity. The main outcome was satisfaction with the outcome of treatment, assessed at baseline and 3, 6, and 12 months later. Additional outcomes were enablement and expectation fulfillment. Results Satisfaction improved over time in the 3 groups (odds ratio = 1.15; 95% confidence interval: 1.10, 1.20; P<.001). There was a significant group-by-time interaction (P<.001), with increased odds of being satisfied in the groups receiving neck-specific exercises compared to general physical activity. Enablement increased after completion of the intervention in all groups (P<.001). People who received neck-specific exercises reported greater enablement and expectation fulfillment than people prescribed general physical activity (P<.01). Conclusion Exercise interventions for chronic WAD led to increased satisfaction for 12 months following treatment that was unrelated to the type of exercise intervention received. Level of Evidence Therapy, level 1b. Registered January 22, 2012 at www.ClinicalTrials.gov (NCT01528579). J Orthop Sports Phys Ther 2016;46(8):640-649. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6136.
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Sihvonen R, Englund M, Turkiewicz A, Järvinen TLN. Mechanical symptoms as an indication for knee arthroscopy in patients with degenerative meniscus tear: a prospective cohort study. Osteoarthritis Cartilage 2016; 24:1367-75. [PMID: 27038490 DOI: 10.1016/j.joca.2016.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/22/2016] [Accepted: 03/22/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE According to prevailing consensus, patients with mechanical symptoms are those considered to most likely benefit from arthroscopic surgery. The aim of this study was to determine the value of using patients' pre-operative self-reports of mechanical symptoms as a justification surgery in patients with degenerative meniscus tear/knee disease. DESIGN Pragmatic prospective cohort of 900 consecutive patients with symptomatic degenerative knee disease and meniscus tear undergoing arthroscopic partial meniscectomy (APM) was collected from one public orthopedic referral center specialized in arthroscopic surgery during 2007-2011. The patients' subjective satisfaction, self-rated improvement, change in Western Ontario Meniscal Evaluation Tool (WOMET) score, and patients' ratings of the knee using a numerical rating scale (NRS) was assessed at 1 year postoperatively. Multivariable regression models, adjusted for possible confounders and intermediates, were used to compare the outcomes in those with and without preoperative mechanical symptoms. RESULTS The proportion of patients satisfied with their knee 12 months after arthroscopy was significantly lower among those with preoperative mechanical symptoms than among those without (61% vs 75%, multivariable adjusted risk ratio [RR] 0.84; 95% confidence interval [CI] 0.76, 0.92). Similarly, the proportion reporting improvement was lower (RR 0.91; 95% CI 0.85, 0.97). No statistically significant difference was found in change in WOMET or NRS between the two groups. Of those with preoperative mechanical symptoms, 47% reported persistent symptoms at 12 months postoperatively. CONCLUSIONS Our observational data contradicts the current tenet of using patients' self-report of mechanical symptoms as a justification for performing arthroscopic surgery on patients with degenerative meniscus tear.
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Affiliation(s)
- R Sihvonen
- Department of Orthopaedics and Traumatology, Hatanpää Hospital and University of Tampere, Tampere, Finland.
| | - M Englund
- Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA.
| | - A Turkiewicz
- Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - T L N Järvinen
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
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Rolfson O, Bohm E, Franklin P, Lyman S, Denissen G, Dawson J, Dunn J, Eresian Chenok K, Dunbar M, Overgaard S, Garellick G, Lübbeke A. Patient-reported outcome measures in arthroplasty registries Report of the Patient-Reported Outcome Measures Working Group of the International Society of Arthroplasty Registries Part II. Recommendations for selection, administration, and analysis. Acta Orthop 2016; 87 Suppl 1:9-23. [PMID: 27228230 PMCID: PMC4937770 DOI: 10.1080/17453674.2016.1181816] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
- The International Society of Arthroplasty Registries (ISAR) Patient-Reported Outcome Measures (PROMs) Working Group have evaluated and recommended best practices in the selection, administration, and interpretation of PROMs for hip and knee arthroplasty registries. The 2 generic PROMs in common use are the Short Form health surveys (SF-36 or SF-12) and EuroQol 5-dimension (EQ-5D). The Working Group recommends that registries should choose specific PROMs that have been appropriately developed with good measurement properties for arthroplasty patients. The Working Group recommend the use of a 1-item pain question ("During the past 4 weeks, how would you describe the pain you usually have in your [right/left] [hip/knee]?"; response: none, very mild, mild, moderate, or severe) and a single-item satisfaction outcome ("How satisfied are you with your [right/left] [hip/knee] replacement?"; response: very unsatisfied, dissatisfied, neutral, satisfied, or very satisfied). Survey logistics include patient instructions, paper- and electronic-based data collection, reminders for follow-up, centralized as opposed to hospital-based follow-up, sample size, patient- or joint-specific evaluation, collection intervals, frequency of response, missing values, and factors in establishing a PROMs registry program. The Working Group recommends including age, sex, diagnosis at joint, general health status preoperatively, and joint pain and function score in case-mix adjustment models. Interpretation and statistical analysis should consider the absolute level of pain, function, and general health status as well as improvement, missing data, approaches to analysis and case-mix adjustment, minimal clinically important difference, and minimal detectable change. The Working Group recommends data collection immediately before and 1 year after surgery, a threshold of 60% for acceptable frequency of response, documentation of non-responders, and documentation of incomplete or missing data.
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Affiliation(s)
- Ola Rolfson
- Swedish Hip Arthroplasty Register and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Correspondence:
| | - Eric Bohm
- Canadian Joint Replacement Registry and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia Franklin
- FORCE-TJR and University of Massachusetts Medical School, Worcester, MA, USA
| | - Stephen Lyman
- Hospital for Special Surgery and Weill Cornell Medical College, New York, NY, USA
| | - Geke Denissen
- Dutch Arthroplasty Register, Hertogenbosch, the Netherlands
| | - Jill Dawson
- Nuffield Department of Population Health and University of Oxford. Oxford, UK
| | - Jennifer Dunn
- New Zealand Joint Registry and University of Otago, Christchurch, New Zealand
| | | | - Michael Dunbar
- Canadian Joint Replacement Registry and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Søren Overgaard
- Danish Hip Arthroplasty Register and University of Southern Denmark, Odense, Denmark
| | - Göran Garellick
- Swedish Hip Arthroplasty Register and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anne Lübbeke
- Geneva Arthroplasty Registry, Division of Orthopaedic Surgery, Geneva University Hospitals, Geneva, Switzerland
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Connor LO. Developing 'subject matter experts': an improvement methodology programme for acute postoperative pain with patients post major surgery. J Clin Nurs 2016; 25:2629-38. [PMID: 27334830 DOI: 10.1111/jocn.13308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To determine the effectiveness of an improvement methodology initiative, directed at refining the quality of acute pain management of patients in the first 24 hours post major surgery using the Revised American Pain Society Patient Outcome Questionnaire, pre- and post development of a 'subject matter experts' acute pain programme. BACKGROUND Accurately measuring effectiveness of acute pain management post major surgery is intertwined with measuring overall patient satisfaction. A critical element of quality evaluation is obtaining direct feedback from patients about the here-and-now pain experiences post major surgery. METHODS A prospective cross-sectional, observational study was conducted in a large university hospital in Ireland. The questionnaire was completed with patients within 24 hours post major surgery, i.e., cardiothoracic, breast, gynaecological, gastrointestinal and urology surgery. The nurse participants were selected based on their commitment to play a key role in acute pain management. The study consisted of: a pre programme phase (n = 100 patients), an intervention phase - 'subject matter experts' acute pain programme (n = 24 nurses) and a postprogramme phase (n = 100 patients). RESULTS Over a quarter of patients were in severe pain for long periods in the first 24 hours post major surgery. These findings were linked not only to ineffective analgesia from some pain drug therapies but also to contradictory messages from nurses. Over half of the patients' pre- and postintervention reported satisfaction with acute pain management, whereas the remainder were dissatisfied and some sought answers to their suboptimum pain status. The 'subject matter experts' had a noteworthy impact on the patients' pain beliefs. CONCLUSIONS The findings revealed that a 'subject matter experts' acute pain programme can have a positive impact on pain management in the immediate phase post major surgery. RELEVANCE TO CLINICAL PRACTICE The role making of 'subject matter experts' in acute pain is a tactical approach towards achieving optimum patient pain control in the immediate phase post major surgery.
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Affiliation(s)
- Laserina O Connor
- Mater Misericordiae University Hospital, St Vincent's Health Care Group, University College Dublin, Dublin, Ireland.
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Waimann CA, Fernandez-Mazarambroz RJ, Cantor SB, Lopez-Olivo MA, Barbo AG, Landon GC, Siff SJ, Lin H, Suarez-Almazor ME. Effect of Body Mass Index and Psychosocial Traits on Total Knee Replacement Costs in Patients with Osteoarthritis. J Rheumatol 2016; 43:1600-6. [DOI: 10.3899/jrheum.151301] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2016] [Indexed: 11/22/2022]
Abstract
Objective.Clinical and psychosocial attributes are associated with clinical outcomes after total knee replacement (TKR) surgery in patients with osteoarthritis (OA), but their relationship with TKR-related costs is less clear. Our objective was to evaluate the effect of clinical and psychosocial attributes on TKR costs.Methods.We conducted a 6-month prospective cohort study of patients with knee OA who underwent TKR. We examined baseline demographic, clinical [body mass index (BMI) and comorbidities], and psychosocial attributes (social support, locus of control, coping, depression, anxiety, stress, and self-efficacy); baseline and 6-month OA clinical outcomes [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function]; and 6-month direct and indirect TKR-related costs. Multiple regression was performed to identify determinants of TKR-related costs.Results.We included 212 patients; 66% were women, 71% were white, and the mean age was 65.2 years. The mean baseline WOMAC pain score was 55 (SD 19) and WOMAC function score was 54 (SD 20). Mean total TKR-related costs were US$30,831 (SD $9893). Multivariate regression analyses showed that increasing BMI and anxiety levels and decreasing levels of positive social interactions were associated with increased costs. A lower cost scenario with a lower range of normal BMI (19.5), highest positive social interaction, and no anxiety predicted TKR costs to be $22,247. Predicted costs in obese patients (BMI 36) with lowest positive social interaction and highest anxiety were $58,447.Conclusion.Increased baseline BMI, anxiety, and poor social support lead to higher TKR-related costs in patients with knee OA. Preoperative interventions targeting these factors may reduce TKR-related costs, and therefore be cost-effective.
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273
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Fernando RJ, Shapiro FE, Urman RD. Survey Analysis of an Ambulatory Surgical Checklist for Patient Use. AORN J 2016; 102:290.e1-10. [PMID: 26323231 DOI: 10.1016/j.aorn.2015.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/22/2015] [Accepted: 07/24/2015] [Indexed: 01/18/2023]
Abstract
Although checklists are used as tools for providers, they have not been adequately explored as tools for patients. The purpose of this study was to survey the stakeholders on the usefulness of an ambulatory surgical checklist for patients. We performed a cross-sectional study through a survey designed to include both patients and providers. Descriptive analysis of the data was performed based on responses from 35 patients and 52 providers. Overall, 94% of patients and 83% of providers thought the checklist would be beneficial for patients. In addition, 37% of providers indicated potential barriers to checklist implementation, including fear of confusing the patient, making patients doubt the care they were receiving, taking too much time, and lack of resources. Based on survey responses, the study suggests that the ambulatory surgical checklist can potentially facilitate patient education, enable more active patient participation, increase patient satisfaction, and decrease patient anxiety.
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274
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Huijbregts HJTAM, Khan RJK, Fick DP, Jarrett OM, Haebich S. Prosthetic alignment after total knee replacement is not associated with dissatisfaction or change in Oxford Knee Score: A multivariable regression analysis. Knee 2016; 23:535-9. [PMID: 26826945 DOI: 10.1016/j.knee.2015.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/07/2015] [Accepted: 12/19/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Approximately 18% of the patients are dissatisfied with the result of total knee replacement. However, the relation between dissatisfaction and prosthetic alignment has not been investigated before. METHODS We retrospectively analysed prospectively gathered data of all patients who had a primary TKR, preoperative and one-year postoperative Oxford Knee Scores (OKS) and postoperative computed tomography (CT). The CT protocol measures hip-knee-ankle (HKA) angle, and coronal, sagittal and axial component alignment. Satisfaction was defined using a five-item Likert scale. We dichotomised dissatisfaction by combining '(very) dissatisfied' and 'neutral/not sure'. Associations with dissatisfaction and change in OKS were calculated using multivariable logistic and linear regression models. RESULTS 230 TKRs were implanted in 105 men and 106 women. At one year, 12% were (very) dissatisfied and 10% neutral. Coronal alignment of the femoral component was 0.5 degrees more accurate in patients who were satisfied at one year. The other alignment measurements were not different between satisfied and dissatisfied patients. All radiographic measurements had a P-value>0.10 on univariate analyses. At one year, dissatisfaction was associated with the three-months OKS. Change in OKS was associated with three-months OKS, preoperative physical SF-12, preoperative pain and cruciate retaining design. DISCUSSION Neither mechanical axis, nor component alignment, is associated with dissatisfaction at one year following TKR. Patients get the best outcome when pain reduction and function improvement are optimal during the first three months and when the indication to embark on surgery is based on physical limitations rather than on a high pain score. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Henricus J T A M Huijbregts
- The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA 6009, Australia; Hollywood Private Hospital, Monash Avenue, Nedlands, WA 6009, Australia.
| | - Riaz J K Khan
- The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA 6009, Australia; Hollywood Private Hospital, Monash Avenue, Nedlands, WA 6009, Australia; Curtin University, Kent Street, Bentley, WA 6102, Australia; University of Notre Dame, 9 Mouat Street, Fremantle, WA 6959, Australia
| | - Daniel P Fick
- The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA 6009, Australia; Hollywood Private Hospital, Monash Avenue, Nedlands, WA 6009, Australia; Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Olivia M Jarrett
- The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA 6009, Australia
| | - Samantha Haebich
- The Joint Studio, Hollywood Medical Centre, 85 Monash Avenue, Nedlands, WA 6009, Australia
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275
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Lane JV, Hamilton DF, MacDonald DJ, Ellis C, Howie CR. Factors that shape the patient's hospital experience and satisfaction with lower limb arthroplasty: an exploratory thematic analysis. BMJ Open 2016; 6:e010871. [PMID: 27217282 PMCID: PMC4885464 DOI: 10.1136/bmjopen-2015-010871] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE It is generally accepted that the patients' hospital experience can influence their overall satisfaction with the outcome of lower limb arthroplasty; however, little is known about the factors that shape the hospital experience. The aim of this study was to develop an understanding of what patients like and do not like about their hospital experience with a view to providing insight into where service improvements could have the potential to improve the patient experience and their satisfaction, and whether they would recommend the procedure. DESIGN A mixed methods (quan-QUAL) approach. SETTING Large regional teaching hospital. PARTICIPANTS 216 patients who had completed a postoperative postal questionnaire at 12 months following total knee or total hip arthroplasty. OUTCOME MEASURES Overall satisfaction with the outcome of surgery, whether to recommend the procedure to another and the rating of patient hospital experience. Free text comments on the best and worst aspects of their hospital stay were evaluated using qualitative thematic analysis. RESULTS Overall, 77% of patients were satisfied with their surgery, 79% reported a good-excellent hospital experience and 85% would recommend the surgery to another. Qualitative analysis revealed clear themes relating to communication, pain relief and the process experience. Comments on positive aspects of the hospital experience were related to feeling well informed and consulted about their care. Comments on the worst aspects of care were related to being made to wait without explanation, moved to different wards and when they felt invisible to the healthcare staff caring for them. CONCLUSIONS Positive patient experiences were closely linked to effective patient-health professional interactions and logistics of the hospital processes. Within arthroplasty services, the patient experience of healthcare could be enhanced by further attention to concepts of patient-centred care. Practical examples of this include more focus on developing staff-patient communication and the avoidance of 'boarding' procedures.
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Affiliation(s)
- J V Lane
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - D F Hamilton
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - D J MacDonald
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
| | - C Ellis
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - C R Howie
- Department of Orthopaedics and Trauma, University of Edinburgh, Edinburgh, UK
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276
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Affiliation(s)
- Sheldon S Lin
- Department of Orthopaedics, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Michael G Yeranosian
- Department of Orthopaedics, New Jersey Medical School, Rutgers University, Newark, New Jersey
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277
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Abstract
Total knee replacement (TKR) is a procedure used to treat knee arthropathy. Patients' dissatisfaction is still relevant (literature reports dissatisfaction rates as high as 40%). The anterior cruciate ligament is usually removed while performing a total knee arthroplasty, thus changing knee biomechanics. As patients' mean age to surgery is decreasing, bicruciate retaining models, which preserve normal biomechanics, may be useful in increasing patients' outcomes. Limited data concerning bicruciate retaining arthroplasty is available; although clinical results are encouraging, there are concerns regarding surgical exposure, anterior cruciate integrity evaluation, and implant fixation.
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Affiliation(s)
- Andrea Trecci
- "Regina Montis Regalis" Hospital, Via S. Rocchetto 99, Mondovì (CN), Italy
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278
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Briet JP, Hageman MGJS, Overbeek CL, Mudgal C, Ring DC, Vranceanu AM. Factors Associated With Met Expectations in Patients With Hand and Upper Extremity Disorders: A Pilot Study. PSYCHOSOMATICS 2016; 57:401-8. [PMID: 27080458 DOI: 10.1016/j.psym.2016.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE The degree to which patients' expectations are met during an office visit consistently correlates with patients' satisfaction, whereas the relationship between previsit expectations and satisfaction varies. OBJECTIVE The aim of this pilot study was to preliminarily assess the relationship of psychosocial factors, pain intensity, and magnitude of disability to previsit expectations, met expectations, and satisfaction with medical care in patients with hand and upper extremity conditions in a surgical outpatient clinic. METHODS A cohort of 85 outpatients with upper extremity illnesses indicated their previsit expectations (Patients Intention Questionnaire), degree to which these expectations were met (Expectations Met Questionnaire), level of depressive symptoms (Patient Health Questionnaire-2), confidence about the ability to achieve one's goals in spite of pain (Pain Self-Efficacy Questionnaire), pain intensity (Numerical Rating Scale for pain), disability (Disabilities of the Arm Shoulder and Hand, short version; QuickDASH), and satisfaction with the medical visit (Medical Interview Satisfaction Scale). RESULTS Higher previsit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and fewer years of education. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, fewer years of education, and more pain compared to those in the high-met expectations category. Fewer years of education and higher pain intensity predicted higher previsit expectations and explained 19% of variance. CONCLUSION Psychosocial factors affect both previsit expectations and met expectations during an outpatient visit to a hand surgeon. Met expectations, but not previsit expectations, affect satisfaction. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Jan Paul Briet
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Michiel G J S Hageman
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Celeste L Overbeek
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Chaitanya Mudgal
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - David C Ring
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Ana-Maria Vranceanu
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA.
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279
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Frankel L, Sanmartin C, Hawker G, De Coster C, Dunbar M, Bohm E, Noseworthy T. Perspectives of orthopaedic surgeons on patients' appropriateness for total joint arthroplasty: a qualitative study. J Eval Clin Pract 2016; 22:164-70. [PMID: 26347053 DOI: 10.1111/jep.12449] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/17/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES As total joint arthroplasty (TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA. METHODS Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness. RESULTS Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged <50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship. CONCLUSIONS Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway.
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Affiliation(s)
- Lucy Frankel
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Claudia Sanmartin
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gillian Hawker
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Carolyn De Coster
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Michael Dunbar
- Division of Orthopaedics, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Eric Bohm
- Department of Surgery, Concordia Joint Replacement Group, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tom Noseworthy
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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280
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Hamilton DF, Giesinger JM, MacDonald DJ, Simpson AHRW, Howie CR, Giesinger K. Responsiveness and ceiling effects of the Forgotten Joint Score-12 following total hip arthroplasty. Bone Joint Res 2016; 5:87-91. [PMID: 26965167 PMCID: PMC4852794 DOI: 10.1302/2046-3758.53.2000480] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To assess the responsiveness and ceiling/floor effects of the Forgotten Joint Score -12 and to compare these with that of the more widely used Oxford Hip Score (OHS) in patients six and 12 months after primary total hip arthroplasty. METHODS We prospectively collected data at six and 12 months following total hip arthroplasty from 193 patients undergoing surgery at a single centre. Ceiling effects are outlined with frequencies for patients obtaining the lowest or highest possible score. Change over time from six months to 12 months post-surgery is reported as effect size (Cohen's d). RESULTS The mean OHS improved from 40.3 (sd 7.9) at six months to 41.9 (sd 7.2) at 12 months. The mean FJS-12 improved from 56.8 (sd 30.1) at six months to 62.1 (sd 29.0) at 12 months. At six months, 15.5% of patients reached the best possible score (48 points) on the OHS and 8.3% obtained the best score (100 points) on the FJS-12. At 12 months, this percentage increased to 20.8% for the OHS and to 10.4% for the FJS-12. In terms of the effect size (Cohen's d), the change was d = 0.10 for the OHS and d = 0.17 for the FJS-12. CONCLUSIONS The FJS-12 is more responsive to change between six and 12 months following total hip arthroplasty than is the OHS, with the measured ceiling effect for the OHS twice that of the FJS-12. The difference in effect size of change results in substantial differences in required sample size if aiming to detect change between these two time points. This has important implications for powering clinical trials with patient-reported measures as the primary outcome.Cite this article: Dr D. F. Hamilton. Responsiveness and ceiling effects of the Forgotten Joint Score-12 following total hip arthroplasty. Bone Joint Res 2016;5:87-91. DOI: 10.1302/2046-3758.53.2000480.
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Affiliation(s)
- D F Hamilton
- Department of Orthopaedics, University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK.
| | - J M Giesinger
- Department of Psychiatry and Psychotherapy, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria
| | - D J MacDonald
- Department of Orthopaedics, University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - A H R W Simpson
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - C R Howie
- Department of Orthopaedics, University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - K Giesinger
- Department of Orthopaedics, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen, Switzerland
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281
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Cox J, Cormack C, Prendergast M, Celestino H, Willis S, Witteveen M. Patient and provider experience with a new model of care for primary hip and knee arthroplasties. Int J Orthop Trauma Nurs 2016; 20:13-27. [DOI: 10.1016/j.ijotn.2015.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 10/23/2022]
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282
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Tetreault L, Le D, Côté P, Fehlings M. The Practical Application of Clinical Prediction Rules: A Commentary Using Case Examples in Surgical Patients with Degenerative Cervical Myelopathy. Global Spine J 2015; 5:457-65. [PMID: 26682095 PMCID: PMC4671907 DOI: 10.1055/s-0035-1567838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Study Design Commentary. Objective This commentary aims to discuss the practical applications of a clinical prediction rule (CPR) developed to predict functional status in patients undergoing surgery for the treatment of degenerative cervical myelopathy. Methods Clinical cases from the AOSpine CSM-North America study were used to illustrate the application of a prediction rule in a surgical setting and to highlight how this CPR can be used to ultimately enhance patient care. Results A CPR combines signs and symptoms, patient characteristics, and other predictive factors to estimate disease probability, treatment prognosis, or risk of complications. These tools can influence allocation of health care resources, inform clinical decision making, and guide the design of future research studies. In a surgical setting, CPRs can be used to (1) manage patients' expectations of outcome and, in turn, improve overall satisfaction; (2) facilitate shared decision making between patient and physician; (3) identify strategies to optimize surgical results; and (4) reduce heterogeneity of care and align surgeons' perceptions of outcome with objective evidence. Conclusions Valid and clinically-relevant CPRs have tremendous value in a surgical setting.
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Affiliation(s)
- Lindsay Tetreault
- University of Toronto, Institute of Medical Sciences, Toronto, Ontario, Canada
| | - David Le
- University of Toronto, Institute of Medical Sciences, Toronto, Ontario, Canada
| | - Pierre Côté
- Faculty of Health Sciences, University of Ontario Institute of Technology and UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Toronto, Ontario, Canada
| | - Michael Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada,Address for correspondence Michael G. Fehlings, MD, PhD, FRCSC Department of Neurosurgery, University of Toronto, The Toronto Western HospitalUniversity Health Network, Room 4W-449, 399 Bathurst Street, Toronto, Ontario M5T 2S8Canada
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283
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Sesen H, Demirkale I, Karaduman M, Vural CA, Okkaoglu MC, Altay M. Why two-thirds of patients accepted the second session in staged bilateral total knee arthroplasty: a prospective analysis of 111 patients. Knee Surg Sports Traumatol Arthrosc 2015; 23:3585-90. [PMID: 25169111 DOI: 10.1007/s00167-014-3251-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/15/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE In staged bilateral total knee arthroplasty (TKA), regaining functional recovery and a painless joint with fulfilment of patients' expectations at the first stage is an integral part for a patient to progress to the second stage. As patient expectations drive postoperative satisfaction, the challenge is to match patient and surgeon expectations before surgery. Therefore, this study aimed to evaluate the postoperative patient expectations and clinical outcomes and to evaluate the rate of second stage in bilateral staged TKA. METHODS The study included 111 patients; 81 females and 30 males with a median age at surgery of 68 years (range 59-85 years) and 46 were older than 70 years. Postoperative functional data included Knee Society Scores (KSS). Expectation data were collected according to the post-visit 'Questionnaire of Patient Expectations of Healthcare'. RESULTS The overall refusal rate for the second stage was 36.9 % (n = 41). The patients older than 70 years had a higher refusal rate compared to relatively younger patients (< 70 years old) (p = 0.038). Younger age, postoperatively improved KSS, fulfilment of patient expectations of the healthcare process, treatment outcomes and whole expectations were the main determinants for patients accepting the second stage. The most important determinative factors for attendance were 'Process of Healthcare' and subsequently 'Treatment Outcomes' and total questionnaire scores (p < 0.001). CONCLUSION The postoperative perception of healthcare and the treating surgeon's knowledge and responsivity are the major concerns for patients considering second stage TKA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hakan Sesen
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
| | - Ismail Demirkale
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
| | - Mert Karaduman
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
| | - Celal Alp Vural
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
| | - Mustafa Caner Okkaoglu
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
| | - Murat Altay
- Department of Orthopaedics and Traumatology, Kecioren Education and Research Hospital, Ardahan S no 25 Kecioren, 06380, Ankara, Turkey.
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284
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Jameson SS, Mason J, Baker PN, Gregg PJ, Deehan DJ, Reed MR. Implant Optimisation for Primary Hip Replacement in Patients over 60 Years with Osteoarthritis: A Cohort Study of Clinical Outcomes and Implant Costs Using Data from England and Wales. PLoS One 2015; 10:e0140309. [PMID: 26561859 PMCID: PMC4643061 DOI: 10.1371/journal.pone.0140309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/24/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis. METHODS AND FINDINGS Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data. RESULTS EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285). Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients. CONCLUSIONS Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.
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Affiliation(s)
- Simon S. Jameson
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees, TS17 6BH, United Kingdom
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - James Mason
- School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees, TS17 6BH, United Kingdom
| | - Paul N. Baker
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - Paul J. Gregg
- The National Joint Registry for England and Wales, London, United Kingdom
- Department of Orthopaedic Surgery, South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, United Kingdom
| | - David J. Deehan
- Department of Orthopaedic Surgery, Newcastle Hospitals NHS Foundation Trust, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, United Kingdom
| | - Mike R. Reed
- Department of Orthopaedic Surgery, Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland, NE63 9JJ, United Kingdom
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285
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Hofstad JK, Winther SB, Rian T, Foss OA, Husby OS, Wik TS. Perioperative local infiltration anesthesia with ropivacaine has no effect on postoperative pain after total hip arthroplasty. Acta Orthop 2015; 86:654-8. [PMID: 25997827 PMCID: PMC4750762 DOI: 10.3109/17453674.2015.1053775] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The local infiltration analgesia (LIA) technique has been widely used to reduce opioid requirements and to improve postoperative mobilization following total hip arthroplasty (THA). However, the evidence for the efficacy of LIA in THA is not yet clear. We determined whether single-shot LIA in addition to a multimodal analgesic regimen would reduce acute postoperative pain and opioid requirements after THA. PATIENTS AND METHODS 116 patients undergoing primary THA under spinal anesthesia were included in this randomized, double-blind, placebo-controlled trial. All patients received oral opioid-sparing multimodal analgesia: etoricoxib, acetaminophen, and glucocorticoid. The patients were randomized to receive either 150 mL ropivacaine (2 mg/mL) and 0.5 mL epinephrine (1 mg/mL) or 150 mL 0.9% saline. Rescue analgesic consisted of morphine and oxycodone as needed. The primary endpoint was pain during mobilization in the recovery unit. Secondary endpoints were pain during mobilization on the day after surgery and total postoperative opioid requirements on the first postoperative day. RESULTS The levels of pain during mobilization-both in the recovery unit and on the day after surgery-and consumption of opioids on the first postoperative day were similar in the 2 groups. INTERPRETATION LIA did not provide any extra analgesic effect after THA over and above that from the multimodal analgesic regimen used in this study.
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Affiliation(s)
| | - Siri B Winther
- Orthopedic Research Center, Department of Orthopaedic Surgery
| | - Torbjørn Rian
- Department of Anesthesiology, Trondheim University Hospital, Trondheim, Norway
| | - Olav A Foss
- Orthopedic Research Center, Department of Orthopaedic Surgery
| | - Otto S Husby
- Orthopedic Research Center, Department of Orthopaedic Surgery
| | - Tina S Wik
- Orthopedic Research Center, Department of Orthopaedic Surgery
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286
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Hamilton DF, Giesinger JM, Patton JT, MacDonald DJ, Simpson AHRW, Howie CR, Giesinger K. Making the Oxford Hip and Knee Scores meaningful at the patient level through normative scoring and registry data. Bone Joint Res 2015; 4:137-44. [PMID: 26311163 PMCID: PMC4561372 DOI: 10.1302/2046-3758.48.2000524] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives The Oxford Hip and Knee Scores (OHS, OKS) have been demonstrated
to vary according to age and gender, making it difficult to compare
results in cohorts with different demographics. The aim of this
paper was to calculate reference values for different patient groups
and highlight the concept of normative reference data to contextualise an
individual’s outcome. Methods We accessed prospectively collected OHS and OKS data for patients
undergoing lower limb joint arthroplasty at a single orthopaedic
teaching hospital during a five-year period.
T-scores were calculated based on the OHS and OKS distributions. Results Data were obtained from 3203 total hip arthroplasty (THA) patients
and 2742 total knee arthroplasty (TKA) patients. The mean age of
the patient was 68.0 years (sd 11.3, 58.4% women) in the
THA group and in 70.2 (sd 9.4; 57.5% women) in the TKA
group. T-scores were calculated for age and gender subgroups by
operation. Different T-score thresholds are seen at different time
points pre and post surgery. Values are further stratified by operation (THA/TKA)
age and gender. Conclusions Normative data interpretation requires a fundamental shift in
the thinking as to the use of the Oxford Scores. Instead of reporting
actual score points, the patient is rated by their relative position
within the group of all patients undergoing the same procedure.
It is proposed that this form of transformation is beneficial (a)
for more appropriately comparing different patient cohorts and (b)
informing an individual patient how they are progressing compared
with others of their age and gender. Cite this article: Bone Joint Res 2015;4:137–144
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Affiliation(s)
- D F Hamilton
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - J M Giesinger
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - J T Patton
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - D J MacDonald
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - A H R W Simpson
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - C R Howie
- University of Edinburgh, FU413, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - K Giesinger
- Kantonsspital St. Gallen, Rorschacherstrasse 95, CH- 9000 St. Gallen, Switzerland
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287
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Hamilton DF, Howie CR, Burnett R, Simpson AHRW, Patton JT. Dealing with the predicted increase in demand for revision total knee arthroplasty: challenges, risks and opportunities. Bone Joint J 2015; 97-B:723-8. [PMID: 26033049 DOI: 10.1302/0301-620x.97b6.35185] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Worldwide rates of primary and revision total knee arthroplasty (TKA) are rising due to increased longevity of the population and the burden of osteoarthritis. Revision TKA is a technically demanding procedure generating outcomes which are reported to be inferior to those of primary knee arthroplasty, and with a higher risk of complication. Overall, the rate of revision after primary arthroplasty is low, but the number of patients currently living with a TKA suggests a large potential revision healthcare burden. Many patients are now outliving their prosthesis, and consideration must be given to how we are to provide the necessary capacity to meet the rising demand for revision surgery and how to maximise patient outcomes. The purpose of this review was to examine the epidemiology of, and risk factors for, revision knee arthroplasty, and to discuss factors that may enhance patient outcomes.
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Affiliation(s)
- D F Hamilton
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - C R Howie
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - R Burnett
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - A H R W Simpson
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH164SB, UK
| | - J T Patton
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH164SB, UK
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288
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Halawi MJ. Outcome Measures in Total Joint Arthroplasty: Current Status, Challenges, and Future Directions. Orthopedics 2015; 38:e685-9. [PMID: 26270754 DOI: 10.3928/01477447-20150804-55] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/27/2014] [Indexed: 02/03/2023]
Abstract
Total joint arthroplasty (TJA) is the most commonly performed surgical procedure for the treatment of advanced degenerative joint diseases. Numerous outcome measures for TJA have been developed, which can be reported by physicians, patients, or both. Although outcome tools were traditionally centered on morbidity, mortality, and implant survival, the focus has evolved over recent years to joint-specific, disease-specific, activity-specific, general well-being, and quality of life assessments. However, despite the importance of outcome measures in a time of growing demand for TJA and increased government scrutiny fueled by high implant costs, there remains no "gold standard" method to assess the impact of TJA. The aim of this review is to evaluate the currently available literature on outcome measures in joint arthroplasty, highlighting the strengths and limitations of commonly used instruments. Because outcomes are influenced by a multitude of intangible factors, there is an increasing role for assessing patient satisfaction as a simple way to account for the complex aspects of care. Strategies including proper patient selection and establishing realistic expectations preoperatively are critical to optimizing outcomes. In an era of increasing public scrutiny, the current state of conflicting results and variable correlations among outcome measures implores the need for a standardized system that should incorporate a metric for patient satisfaction adjusted for preoperative expectations.
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MESH Headings
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/trends
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/trends
- Forecasting
- Humans
- Male
- Middle Aged
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/surgery
- Patient Outcome Assessment
- Patient Satisfaction
- Patient Selection
- Quality of Life
- Treatment Outcome
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289
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Auer CJ, Glombiewski JA, Doering BK, Winkler A, Laferton JAC, Broadbent E, Rief W. Patients’ Expectations Predict Surgery Outcomes: A Meta-Analysis. Int J Behav Med 2015. [DOI: 10.1007/s12529-015-9500-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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290
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Lim CR, Harris K, Dawson J, Beard DJ, Fitzpatrick R, Price AJ. Floor and ceiling effects in the OHS: an analysis of the NHS PROMs data set. BMJ Open 2015; 5:e007765. [PMID: 26216152 PMCID: PMC4521553 DOI: 10.1136/bmjopen-2015-007765] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES The objective was to examine whether the Oxford Hip Score (OHS) demonstrated a floor or a ceiling effect when used to measure the outcome of hip replacement surgery in a large national cohort. SETTING Secondary database analysis of a national audit conducted in England and Wales on patient undergoing hip and knee arthroplasty in a secondary care setting. PARTICIPANTS 93 253 primary arthroplasty patients completed preoperative OHS questionnaires and 69 361 completed 6-month postoperative OHS questionnaires. The population had a mean age of 67.78 (range 14-100, SD 11.3) and 59% were female. PRIMARY SECONDARY OUTCOME MEASURES Primary outcome measure was the Oxford Hip Score (OHS). Secondary outcome measures were the OHS-FCS and OHS-PCS. Floor and ceiling effects were considered present if >15% of patients achieved the worst score/floor effect (0/48) or best/ceiling effect (48/48) score. RESULTS Preoperatively, 0% of patients achieved the best score (48) and 0.1% achieved the worst score (0). Postoperatively, 0.1% patients achieved the worst score, but the percentage achieving the best score increased to 11.6%. Subgroup analyses demonstrated that patients between 50 and 59 years of age had the highest postoperative best score, at 15.3%. The highest postoperative OHS worst score percentage was in a group of patients who had a preoperative OHS above 41/48 at 28%. Furthermore, 22.6% of patients achieved the best postoperative OHS-PCS and 19.9% best postoperative OHS-FCS. CONCLUSIONS Based on NHS PROMS data the overall OHS does not exhibit a ceiling or floor effect and should continue to be used as a valid measure of patient-reported outcomes for patients undergoing total hip arthroplasty. However, subscale analysis does indicate some limitations in the OHS-PCS and OHS-FCS. TRIAL REGISTRATION NUMBER NDORMS. Introducing standardised and evidence-based thresholds for hip and knee replacement surgery. The Arthroplasty Candidacy Help Engine (ACHE tool). HTA Project 11/63/01.
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Affiliation(s)
- Christopher R Lim
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Kristina Harris
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jill Dawson
- Department of Public Health, Oxford University, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Health Services Research Unit, Oxford University, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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291
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Rolfson O, Malchau H. The use of patient-reported outcomes after routine arthroplasty: beyond the whys and ifs. Bone Joint J 2015; 97-B:578-81. [PMID: 25922448 DOI: 10.1302/0301-620x.97b5.35356] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The limitations and benefits of patient-reported outcome measures, in defining the merits of arthroplasty surgery, are discussed.
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Affiliation(s)
- O Rolfson
- Swedish Hip Arthroplasty Register, Centre of Registers Västra Götaland, SE-413 45 Gothenburg, Sweden
| | - H Malchau
- Sahlgrenska University Hospital, SE-431 80 Mölndal, Sweden
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292
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Hawker G, Bohm ER, Conner-Spady B, De Coster C, Dunbar M, Hennigar A, Loucks L, Marshall DA, Pomey MP, Sanmartin C, Noseworthy T. Perspectives of Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and Knee Osteoarthritis. Arthritis Rheumatol 2015; 67:1806-15. [DOI: 10.1002/art.39124] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 03/17/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Gillian Hawker
- Women's College Hospital and University of Toronto, Toronto; Ontario Canada
| | - Eric R. Bohm
- University of Manitoba and Concordia Joint Replacement Group; Winnipeg Manitoba Canada
| | | | | | | | | | - Lynda Loucks
- Concordia Joint Replacement Group; Winnipeg Manitoba Canada
| | | | | | - Claudia Sanmartin
- University of Calgary, Calgary, Alberta, Canada, and Statistics Canada; Ottawa Ontario Canada
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293
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Günther KP, Haase E, Lange T, Kopkow C, Schmitt J, Jeszenszky C, Balck F, Lützner J, Hartmann A, Lippmann M. [Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]. DER ORTHOPADE 2015; 44:555-65. [PMID: 25925089 DOI: 10.1007/s00132-015-3097-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty. OBJECTIVES To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction. MATERIALS AND METHODS Review of relevant clinical studies, meta-analyses, and presentation of our own results. RESULTS Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction. CONCLUSIONS It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.
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Affiliation(s)
- K-P Günther
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
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294
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Lim JBT, Chou ACC, Yeo W, Lo NN, Chia SL, Chin PL, Tay DKJ, Yeo SJ. Comparison of patient quality of life scores and satisfaction after common orthopedic surgical interventions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1007-12. [DOI: 10.1007/s00590-015-1635-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/14/2015] [Indexed: 01/11/2023]
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295
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Langlois J, Zaoui A, Ozil C, Courpied JP, Anract P, Hamadouche M. Randomized controlled trial of conventional versus modern surgical dressings following primary total hip and knee replacement. INTERNATIONAL ORTHOPAEDICS 2015; 39:1315-9. [DOI: 10.1007/s00264-015-2726-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/25/2015] [Indexed: 11/25/2022]
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296
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Hamilton DF, Burnett R, Patton JT, Howie CR, Moran M, Simpson AHRW, Gaston P. Implant design influences patient outcome after total knee arthroplasty: a prospective double-blind randomised controlled trial. Bone Joint J 2015; 97-B:64-70. [PMID: 25568415 DOI: 10.1302/0301-620x.97b1.34254] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Total knee arthroplasty (TKA) is an established and successful procedure. However, the design of prostheses continues to be modified in an attempt to optimise the functional outcome of the patient. The aim of this study was to determine if patient outcome after TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%), 81 male (32%)) were enrolled in a single centre double-blind trial and randomised to receive either a Kinemax (group 1) or a Triathlon (group 2) TKA. Patients were assessed pre-operatively, at six weeks, six months, one year and three years after surgery. The outcome assessments used were the Oxford Knee Score; range of movement; pain numerical rating scales; lower limb power output; timed functional assessment battery and a satisfaction survey. Data were assessed incorporating change over all assessment time points, using repeated measures analysis of variance longitudinal mixed models. Implant group 2 showed a significantly greater range of movement (p = 0.009), greater lower limb power output (p = 0.026) and reduced report of 'worst daily pain' (p = 0.003) over the three years of follow-up. Differences in Oxford Knee Score (p = 0.09), report of 'average daily pain' (p = 0.57) and timed functional performance tasks (p = 0.23) did not reach statistical significance. Satisfaction with outcome was significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced by the prosthesis used.
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Affiliation(s)
- D F Hamilton
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - R Burnett
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - J T Patton
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - C R Howie
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - M Moran
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - A H R W Simpson
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - P Gaston
- University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
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297
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Jameson SS, Mason JM, Baker PN, Gregg PJ, Deehan DJ, Reed MR. No functional benefit of larger femoral heads and alternative bearings at 6 months following primary hip replacement. Acta Orthop 2015; 86:32-40. [PMID: 25301437 PMCID: PMC4366669 DOI: 10.3109/17453674.2014.972259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There has been a recent trend towards the use of greater femoral head sizes in an attempt to improve function and enhance stability after primary hip replacement. This has been associated with the use of alternative bearings, theoretically to reduce wear and improve implant longevity. METHODS We examined the influence of these variables on patient-reported outcome measures (PROMs) for a consecutive series of primary hip replacements using National Joint Registry (NJR) and PROMs-linked data. To minimize the confounding influence of implant design factors, the single most commonly used brand in England and Wales (DePuy Corail Pinnacle) was examined. Improvement in patient hip-specific outcomes (Oxford hip score, OHS), general health outcomes (Euroqol, EQ-5D), and rates of self-reported complications (bleeding, wound problems, re-admission, and reoperation) were compared for different head sizes (28-mm, 32-mm, and 36-mm) and bearings (metal-on-polyethylene (MoP), ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC)), adjusting for differences in case mix. RESULTS At a mean follow-up of 7 months, improvements in OHS and EQ5D index were similar for 28-mm and 36-mm heads. A 32-mm head was associated with poorer function (OHS: 20, 99% CI: 19-21, p = 0.002; EQ5D index: 0.39, 99% CI: 0.36-0.42, p = 0.004), although these small differences may not be of clinical importance. There were no statistically significant benefits of either CoP or CoC bearings compared to a MoP bearing. Complication rates were similar within comparisons of head sizes or bearings. INTERPRETATION In this short-term study, we did not find any functional benefits of larger head sizes or alternative bearings, after adjusting for other influences. We question their use in routine primary hip replacement given the lack of evidence of improved long-term survival in the literature.
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Affiliation(s)
- Simon S Jameson
- The National Joint Registry for England and Wales,School of Medicine, Pharmacy and Health, Durham University, Queen’s Campus, Stockton-on-Tees
| | - James M Mason
- School of Medicine, Pharmacy and Health, Durham University, Queen’s Campus, Stockton-on-Tees
| | - Paul N Baker
- The National Joint Registry for England and Wales
| | - Paul J Gregg
- The National Joint Registry for England and Wales
| | - David J Deehan
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne
| | - Mike R Reed
- Northumbria Healthcare NHS Foundation Trust, Ashington, Northumberland, UK
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298
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Younger ASE, Wing KJ, Glazebrook M, Daniels TR, Dryden PJ, Lalonde KA, Wong H, Qian H, Penner M. Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion. Foot Ankle Int 2015; 36:123-34. [PMID: 25645533 DOI: 10.1177/1071100714565902] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Current operative outcome scales are based on pain and function, such as the Ankle Osteoarthritis Scale (AOS). Outcomes based on patient expectation and satisfaction may be more useful. The purpose of this prospective cohort study was to evaluate associations between patient expectation, satisfaction, and outcome scores for ankle fusion and total ankle replacement (TAR). METHODS In total, 654 ankles in 622 patients were analyzed at a mean of 61 months. Patient expectation and satisfaction with symptoms were quantified pre- and postoperatively using the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaires from the American Academy of Orthopaedic Surgeons, while function was quantified using the AOS. RESULTS Patients undergoing ankle replacement had a higher preoperative expectation score (79; 95% confidence interval [CI], 77-81) compared with those undergoing ankle fusion (72; 95% CI, 68-75). Preoperative expectation scores correlated weakly with AOS scores (R (2) = 0.02) and with the "expectations met" score for ankle fusion (R (2) = 0.07) but not for ankle replacement (R (2) < 0.01). Satisfaction scores were similar for ankle fusion and ankle replacement at follow-up, but a greater number of ankle replacement patients showed improvement in satisfaction (84% vs 74%, P < .005). Higher satisfaction at final follow-up was associated with better expectations met and greater improvement in AOS outcome scores for both ankle fusion and ankle replacement. Expectations met and AOS scores at follow-up correlated for ankle fusion (R (2) = 0.38, P < .0001) and ankle replacement (R (2) = 0.31, P < .0001). CONCLUSIONS Patients undergoing TAR had higher expectation scores prior to surgery than those undergoing ankle fusion. Expectations may be more likely to be met by ankle replacement compared with ankle fusion. Ankle replacement patients were more likely to report improved satisfaction scores after surgery. Preoperative expectation scores showed little correlation with preoperative AOS scores, indicating that expectation is independent of pain and function. However, postoperative expectations met and satisfaction scores were strongly associated with AOS scores at follow-up. Better preoperative patient education may change expectations and requires study. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Alastair S E Younger
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Kevin J Wing
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Mark Glazebrook
- Department of Orthopedic Surgery, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
| | | | | | | | - Hubert Wong
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Hong Qian
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Murray Penner
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
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299
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Jameson SS, Mason J, Baker P, Gregg PJ, Porter M, Deehan DJ, Reed MR. Have cementless and resurfacing components improved the medium-term results of hip replacement for patients under 60 years of age? Acta Orthop 2015; 86:7-17. [PMID: 25285617 PMCID: PMC4366667 DOI: 10.3109/17453674.2014.972256] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 04/05/2014] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The optimal hip replacement for young patients remains unknown. We compared patient-reported outcome measures (PROMs), revision risk, and implant costs over a range of hip replacements. METHODS We included hip replacements for osteoarthritis in patients under 60 years of age performed between 2003 and 2010 using the commonest brand of cemented, cementless, hybrid, or resurfacing prosthesis (11,622 women and 13,087 men). The reference implant comprised a cemented stem with a conventional polyethylene cemented cup and a standard-sized head (28- or 32-mm). Differences in implant survival were assessed using competing-risks models, adjusted for known prognostic influences. Analysis of covariance was used to assess improvement in PROMs (Oxford hip score (OHS) and EQ5D index) in 2014 linked procedures. RESULTS In males, PROMs and implant survival were similar across all types of implants. In females, revision was statistically significantly higher in hard-bearing and/or small-stem cementless implants (hazard ratio (HR) = 4) and resurfacings (small head sizes (< 48 mm): HR = 6; large head sizes (≥ 48 mm): HR = 5) when compared to the reference cemented implant. In component combinations with equivalent survival, women reported significantly greater improvements in OHS with hybrid implants (22, p = 0.006) and cementless implants (21, p = 0.03) (reference, 18), but similar EQ5D index. For men and women, National Health Service (NHS) costs were lowest with the reference implant and highest with a hard-bearing cementless replacement. INTERPRETATION In young women, hybrids offer a balance of good early functional improvement and low revision risk. Fully cementless and resurfacing components are more costly and do not provide any additional benefit for younger patients.
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Affiliation(s)
- Simon S Jameson
- School of Medicine, Pharmacy and Health , Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees , UK
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Haase E, Lange T, Lützner J, Kopkow C, Petzold T, Günther KP, Schmitt J. Indikation zur endoprothetischen Versorgung des Kniegelenks – ein Evidence Mapping. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2015; 109:605-14. [DOI: 10.1016/j.zefq.2015.09.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 01/01/2023]
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