What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement

Have cementless and resurfacing components improved the medium-term results of hip replacement for patients under 60 years of age?

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.

Patients' Perspectives of Surgical Safety: Do They Feel Safe?

BACKGROUND

Increased focus on reducing patient harm has led to surgical safety initiatives, including time-out, surgical safety checklists, and debriefings. The perception of the lay public of the surgical safety process is largely unknown.

METHODS

A 20-question survey focused on perceptions of surgical safety practice was distributed to a random sample of patients following elective operations requiring hospitalization. Responses were measured by a 7-point Likert scale. Qualitative feedback was obtained through nonphysician-moderated sessions. Participation was voluntary and anonymous.

RESULTS

Surveys were distributed to 345 patients of whom 102 (29.5%) responded. Overall, patients felt safe as evidenced by scores for the questions "I felt safe the day of my surgery" (6.53 ± 0.72) and "Mistakes rarely happen during surgery" (5.39 ± 1.51). Patients undergoing their first surgery and patients with higher income levels were associated with a significant decrease in specific safety perceptions. Qualitative feedback sessions identified the physician-patient relationship as the most important factor positively influencing patient safety perceptions.

CONCLUSION

Current surgical safety practice is perceived positively by our patients; however, patients still identify physician-patient interactions, relationships, and trust as the most positive factors influencing their perception of the safety environment.

Robotic and navigation systems in orthopaedic surgery: how much do our patients understand?

BACKGROUND

Technology in orthopaedic surgery has become more widespread in the past 20 years, with emerging evidence of its benefits in arthroplasty. Although patients are aware of benefits of conventional joint replacement, little is known on patients' knowledge of the prevalence, benefits or drawbacks of surgery involving navigation or robotic systems.

METHODS

In an outpatient arthroplasty clinic, 100 consecutive patients were approached and given questionnaires to assess their knowledge of navigation and robotics in orthopaedic surgery. Participation in the survey was voluntary.

RESULTS

Ninety-eight patients volunteered to participate in the survey, mean age 56.2 years (range, 19 to 88 years; 52 female, 46 male). Forty percent of patients thought more than 30% of National Health Service (NHS) orthopaedic operations involved navigation or robotics; 80% believed this was the same level or less than the private sector. One-third believed most of an operation could be performed independently by a robotic/navigation system. Amongst perceived benefits of navigation/robotic surgery was more accurate surgery (47%), quicker surgery (50%), and making the surgeon's job easier (52%). Sixty-nine percent believed navigation/robotics was more expensive and 20% believed it held no benefit against conventional surgery, with only 9% believing it led to longer surgery. Almost 50% would not mind at least some of their operation being performed with use of robotics/navigation.

CONCLUSIONS

Although few patients were familiar with this new technology, there appeared to be a strong consensus it was quicker and more accurate than conventional surgery. Many patients appear to believe navigation and robotics in orthopaedic surgery is largely the preserve of the private sector. This study demonstrates public knowledge of such new technologies is limited and a need to inform patients of the relative merits and drawbacks of such surgery prior to their more widespread implementation.

How do we face patients' expectations in joint arthroplasty?

INTRODUCTION

Patients' expectations have become increasingly important over the last decade, as the fulfilment of preoperative expectations has been shown to be associated with postoperative satisfaction. Understanding the pattern of patients' expectations is necessary to provide a better basis for recommendations to patients opting for arthroplasty. The aim of this study was to show patients' expectations of joint replacement surgery in Germany and to elucidate factors, which might have an influence.

MATERIALS AND METHODS

A retrospective analysis of anonymously collected data was performed on people participating in a patient information event for joint replacement surgery. They were asked to complete a survey, which consisted of five questions requesting demographic data and three questions regarding preoperative expectations. The latter were taken from the New Knee Society Score. An expectation score (0-12 points) was generated by adding the single point values of the three questions.

RESULTS

180 attendees were included in this study. The distribution of patients' expectations was remarkably skewed towards high expectations, the mean expectation score was 10.17. 87.2 % of participants had high and very high expectations and only 12.8 % had low and moderate expectations. Patients' expectations were independent of age and previous participation in a patient information event. Female gender and a history of arthroplasty led to a slightly higher expectation score. Patients with isolated knee pain had significantly lower expectations than patients suffering from isolated hip pain.

CONCLUSIONS

This study shows that the majority of patients have high expectations regarding joint replacement surgery. To improve postoperative patients' satisfaction a straightforward physician-patient communication is necessary to prevent patients from potentially unrealistic expectations and therefore dissatisfaction with surgery.

Communication intervention in the neonatal intensive care unit: can it backfire?

BACKGROUND

For parents of a critically ill infant, good communication may help alleviate stress and anxiety. To improve communication, physicians must be responsive to families' needs and values surrounding the care of their hospitalized infant.

OBJECTIVE

We adapted a Decision-Making Tool for the Neonatal Intensive Care Unit (N-DMT) to encourage consideration of family concerns and preferences in daily care planning.

DESIGN

This was a randomized controlled design.

SETTING/SUBJECTS

Parents and providers of critically ill neonates were eligible. Parents were randomized to an intervention group (using the N-DMT) or standard of care. N-DMT information was shared through the electronic medical record and communicated directly to the primary provider.

MEASUREMENTS

Daily rounds on all infants were audio recorded. Parents completed the State-Trait Anxiety Inventory at the first interview and 2 weeks later. Parents completed the Family Inventory of Needs-Pediatrics (FIN-PED) survey and an N-DMT-specific survey 2 weeks postenrollment.

RESULTS

Complete data were obtained on 10 control and 9 intervention families. Groups did not differ on demographics or mean infant Score of Neonatal Acute Physiology (SNAP) scores (36 versus 37). FIN-PED scores were similar for both groups. The control group showed decreased anxiety over time. The content of rounds did not differ between groups. The intervention group reported lower satisfaction with care, specifically in questions regarding communication.

CONCLUSIONS

In this pilot study, we found that families in the intervention group were less satisfied with communication. Families who are primed to expect better communication, such as those participating in a communication intervention, may be less satisfied with standard care.

Assessing treatment outcomes using a single question: the net promoter score

Satisfaction with care is important to both patients and to those who pay for it. The Net Promoter Score (NPS), widely used in the service industries, has been introduced into the NHS as the 'friends and family test'; an overarching measure of patient satisfaction. It assesses the likelihood of the patient recommending the healthcare received to another, and is seen as a discriminator of healthcare performance. We prospectively assessed 6186 individuals undergoing primary lower limb joint replacement at a single university hospital to determine the Net Promoter Score for joint replacements and to evaluate which factors contributed to the response. Achieving pain relief (odds ratio (OR) 2.13, confidence interval (CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR 2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI 2.03 to 2.68) are the domains that explain whether a patient would recommend joint replacement services. These three factors, combined with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17), drove a predictive model that was able to explain 95% of the variation in the patient's recommendation response. Though intuitively similar, this 'recommendation' metric was found to be materially different to satisfaction responses. The difference between THR (NPS 71) and TKR (NPS 49) suggests that no overarching score for a department should be used without an adjustment for case mix. However, the Net Promoter Score does measure a further important dimension to our existing metrics: the patient experience of healthcare delivery.

Outcomes of a joint replacement surgical home model clinical pathway

Optimizing perioperative care to provide maximum benefit at minimum cost may be best achieved using a perioperative clinical pathway (PCP). Using our joint replacement surgical home (JSH) model PCP, we examined length of stay (LOS) following total joint arthroplasty (TJA) to evaluate patient care optimization. We reviewed a spectrum of clinical measurements in 190 consecutive patients who underwent TJA. Patients who had surgery earlier in the week and who were earlier cases of the day had a significantly lower LOS than patients whose cases started both later in the week and later in the day. Patients discharged home had significantly lower LOS than those discharged to a secondary care facility. Patients who received regional versus general anesthesia had a significantly lower LOS. Scheduling patients discharged to home and who will likely receive regional anesthesia for the earliest morning slot and earlier in the week may help decrease overall LOS.

Staged bilateral total knee replacement

We explored the outcome of staged bilateral total knee replacement (TKR) for symmetrical degenerative joint disease and deformity in terms of patient expectations, functional outcome and satisfaction. From 2009 to 2011, 70 consecutive patients (41 female) with a mean age of 71.7 years (43 to 89) underwent 140 staged bilateral TKRs at our institution, with a mean time between operations of 7.8 months (2 to 25). Patients were assessed pre-operatively and at six and 12 months post-operatively using the Short Form-12, Oxford knee score (OKS), expectation questionnaire and satisfaction score. The pre-operative OKS was significantly worse before the first TKR (TKR1), but displayed significantly greater improvement than that observed after the second TKR (TKR2). Expectation level increased from TKR1 to TKR2 in 17% and decreased in 20%. Expectations of pain relief and stair-climbing were less before TKR2; in contrast, expectations of sporting and social activities were greater. Decreased expectations of TKR2 were significantly associated with younger age and high expectations before TKR1. Patient satisfaction was high for both TKR1 (93%) and TKR2 (87%) but did not correlate significantly within individuals. We concluded that satisfaction with one TKR does not necessarily translate to satisfaction following the second.

Cite this article: Bone Joint J 2014;96-B:752–8.

Associations between patient expectations of joint arthroplasty surgery and pre- and post-operative clinical status

Improvements in implant materials and designs have broadened surgical indications and improved the technical successes of joint arthroplasty surgery. Nevertheless, a small but notable proportion of patients remain dissatisfied despite technically successful surgery. Given reported associations between unfulfilled patient expectations and dissatisfaction, we performed a systematic review to investigate the current state of knowledge concerning potential associations between clinical status and patient expectations of joint arthroplasty procedures. A wide range of expectation assessment instruments was identified, some of which assessed probabilistic expectations and other value-based expectations. Consistent associations were identified between probabilistic expectations of surgery and better pre-operative disease-specific and general health status, as well as more desirable post-operative disease specific scores. In contrast, no consistent associations were identified between clinical status and value-based expectations. Fulfillment of expectations was consistently associated with superior disease-specific and general health absolute and change scores, irrespective of the expectations paradigm used.

Patient satisfaction and self-reported outcomes after complete brachial plexus avulsion injury

PURPOSE

Reconstructive surgery for complete brachial plexus avulsion injuries only partially restores function, and many patients are dissatisfied with results that surgeons consider good. Preoperative expectations have been shown to influence postoperative satisfaction but are poorly understood in patients with complete brachial plexus avulsion injuries. Qualitative methodology can elucidate patient beliefs and attitudes, which are difficult to quantify. The purpose of this study was to examine patient-reported outcomes, including satisfaction, and to understand the patient perspective.

METHODS

We used qualitative interviews and questionnaires to assess patient-reported outcomes. Two members of the research team analyzed interview data using Grounded Theory methodology. Data from participants who had and did not have reconstructive surgery were compared.

RESULTS

Twelve patients participated in this study. Of the 7 participants who had reconstructive surgery, 4 felt their expectations had been met and 5 were satisfied with their outcomes. Reconstruction did not produce statistically significant improvements in upper extremity function, pain, or work ability. All patients reported dissatisfaction with upper extremity ability, and 9 expressed hope for innovative treatments (e.g., stem cell therapy, nerve reinsertion) that could potentially provide better outcomes than existing procedures and enable return to work.

CONCLUSIONS

Satisfaction with surgical outcomes after complete avulsion brachial plexus injury depends heavily on whether preoperative expectations are met, but patients are unfamiliar with nerve avulsion and do not always know what to expect. Low satisfaction with upper extremity ability and the lack of statistically significant differences produced by reconstruction suggest that current treatments may not be meeting patients' needs. Physicians must provide robust preoperative education to encourage realistic expectations and direct patients toward resources for pain management to facilitate comprehensive rehabilitation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Personality, function and satisfaction in patients undergoing total hip or knee replacement

BACKGROUND

The aim of this study was to investigate the relationships between personality and joint-specific function, general physical and general mental health in patients undergoing total hip (THA) and knee arthroplasty (TKA).

METHODS

One hundred and eighty-four patients undergoing THA and 205 undergoing TKA were assessed using the Eysneck Personality Questionnaire, brief version (EPQ-BV). General physical and mental health was measured using the Short-Form 12 (SF-12) questionnaire and the EuroQol (EQ-5D). Joint-specific function was measured using the Oxford hip or knee score.

RESULTS

The "unstable introvert" personality type was associated with poorer pre-operative function and health in patients with hip arthrosis. In patients with knee arthrosis, there was poorer general health in those with "stable extrovert" and "unstable introvert" types. Personality was not an independent predictor of outcome following TKA or THA. The main predictor was pre-operative function and health. Comorbidity was an important covariate of both pre-operative and postoperative function.

CONCLUSIONS

Personality may play a role in the interaction of these disease processes with function and health perception. It may also affect the response and interpretation of psychometric and patient-reported outcome measures. It may be important to characterise and identify these traits in potential arthroplasty patients as it may help deliver targeted education and management to improve outcomes in certain groups.

Comparative responsiveness of outcome measures for total knee arthroplasty

OBJECTIVE

The aim of this study was to compare the responsiveness of various patient-reported outcome measures (PROMs) and clinician-reported outcomes following total knee arthroplasty (TKA) over a 2-year period.

METHODS

Data were collected in a prospective cohort study of primary TKA. Patients who had completed Forgotten Joint Score-12 (FJS-12), Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index, EQ-5D, Knee Society Score and range of movement (ROM) assessment were included. Five time points were assessed: pre-operative, 2 months, 6 months, 1 year and 2 years post-operative.

RESULTS

Data from 98 TKAs were available for analysis. Largest effect sizes (ES) for change from pre-operative to 2-month follow-up were observed for the Knee Society Score (KSS) Knee score (1.70) and WOMAC Total (-1.50). For the period from 6 months to 1 year the largest ES for change were shown by the FJS-12 (0.99) and the KSS Function Score (0.88). The EQ-5D showed the strongest ceiling effect at 1-year follow-up with 84.4% of patients scoring the maximum score. ES for the time from 1- to 2-year follow-up were largest for the FJS-12 (0.50). All other outcome measures showed ES equal or below 0.30.

CONCLUSION

Outcome measures differ considerably in responsiveness, especially beyond one year post-operatively. Joint-specific outcome measures are more responsive than clinician-reported or generic health outcome tools. The FJS-12 was the most responsive of the tools assessed; suggesting that joint awareness may be a more discerning measure of patient outcome than traditional PROMs.

Targeted rehabilitation to improve outcome after total knee replacement (TRIO): study protocol for a randomised controlled trial

Background

Approximately 20% of patients are not satisfied with the outcome of total knee replacement, great volumes of which are carried out yearly. Physiotherapy is often provided by the NHS to address dysfunction following knee replacement; however the efficacy of this is unknown. Although clinically it is accepted that therapy is useful, provision of physiotherapy to all patients post-operatively does not enhance outcomes at one year. No study has previously assessed the effect of targeting therapy to individuals struggling to recover in the early post-operative phase.

The aim of the TRIO study is to determine whether stratifying care by targeting physiotherapy to those individuals performing poorly following knee replacement is effective in improving the one year outcomes. We are also investigating whether the structure of the physiotherapy provision itself influences outcomes.

Methods/Design

The study is a multi-centre prospective randomised controlled trial (RCT) of patients undergoing primary total knee replacement, with treatment targeted at those deemed most susceptible to gain from it. Use of the national PROMS programme for pre-operative data collection allows us to screen all patients at initial post-operative clinical review, and recruit only those deemed to be recovering slowly.

We aim to recruit 440 patients through various NHS orthopaedic centres who will undergo six weeks of physiotherapy. The intervention will be either ‘intensive’ involving both hospital and home-based functional exercise rehabilitation, or ‘standard of care’ consisting of home exercises. Patients will be randomised to either group using a web-based system. Both groups will receive pre and post-intervention physiotherapy review. Patients will be followed-up to one year post-operation. The primary outcome measure is the Oxford Knee Score. Secondary outcomes are patient satisfaction, functional ability, pain scores and cost-effectiveness.

Trial registration

Current Controlled Trials ISRCTN23357609. ClinicalTrials.gov NCT01849445.

I can't get no satisfaction after my total knee replacement: rhymes and reasons

Satisfaction is increasingly employed as an outcome measure for a successful total knee replacement (TKR). Satisfaction as an outcome measure encompasses many different intrinsic and extrinsic factors related to a person's experience before and after TKR. The Swedish Knee Arthroplasty Registry has previously demonstrated on a large population study that 17% of TKR recipients are not satisfied with their TKR outcome. This finding has been replicated in other countries. Similar significant factors emerged from these registry studies that are related to satisfaction. It would appear that satisfaction is better after more chronic diseases and whether the TKR results in pain relief or improved function. Importantly, unmet pre-operative expectations are a significant predictor for dissatisfaction following a TKR. It may be possible to improve rates by addressing the issues surrounding pain, function and expectation before embarking on surgery.

An exploration of patients' expectation of and satisfaction with surgical outcome

Purpose

The majority of studies of surgical outcome focus on measures of function and pain. Increasingly, however, the desire to include domains such as patients’ satisfaction and expectations had led to the development of simple measures and their inclusion into clinical studies. The purpose of this study was to determine patients’ pre-operative expectations of and post-operative satisfaction with the outcome of their spinal surgery.

Methods

As part of the FASTER randomised controlled trial, patients were asked pre-operatively to quantify their expected improvement in pain and health status at 6 weeks, 6 and 12 months following surgery using 100 mm visual analogue scales (VAS), and to indicate their confidence in achieving this result and also the importance of this recovery to them. Patients were then asked to rate their satisfaction with the improvement achieved at each post-operative review using 100 mm VAS.

Results

Although differences between patients’ expectation and achievement were minimal 6 weeks post-operatively, there was a clear discrepancy at 6 months and 1 year, with patient expectations far exceeding achievement. There were significant correlations between failure to achieve expectations and the importance patients attached to this recovery at each post-operative assessment, but not with their confidence in achieving this result. Satisfaction levels remained high despite expectations not being met, with discectomy patients being more satisfied than decompression patients.

Conclusions

Patients’ pre-operative expectations of surgical outcome exceed their long-term achievement. The more importance the patient attached to a good outcome, the larger is the discrepancy between expectation and achievement. Despite this, satisfaction levels remained high. The impact of unrealistic expectations on outcome remains unclear.