Musculoskeletal Health Literacy is Associated With Outcome and Satisfaction of Total Knee Arthroplasty

Readability and quality of online patient resources regarding knee osteoarthritis and lumbar spinal stenosis in Japan

BACKGROUND

This study aimed to quantify the readability and quality of online patient resources on knee osteoarthritis and lumbar spinal stenosis in Japan.

METHODS

Three search engines (Google, Yahoo, and Bing) were searched for the terms knee osteoarthritis and lumbar spinal stenosis. The first 30 websites of each search were screened. Duplicate websites and those unrelated to the searched diseases were excluded. The remaining 125 websites (62 on knee osteoarthritis, 63 on lumbar spinal stenosis) were analyzed. The text readability was assessed using two web-based programs (Obi-3 and Readability Research Lab) and lexical density. Website quality was evaluated using the DISCERN score, Clear Communication Index, and Journal of American Medical Association benchmark criteria.

RESULTS

Readability scores were high, indicating that the texts were difficult to understand. Only 24 (19%) and six (5%) websites were classified as average difficulty readability according to Obi-3 and Readability Research Lab, respectively. The overall quality of information was low, with only four (3%) being rated as having sufficient quality based on the Clear Communication Index and Journal of American Medical Association benchmark criteria. None of the websites satisfied the DISCERN quality criteria.

CONCLUSIONS

Patient information on Japanese websites regarding knee osteoarthritis and lumbar spinal stenosis were difficult to understand. Moreover, the quality of the websites was insufficient. Orthopaedic surgeons should contribute to the creation of high-quality easy-to-read websites to facilitate patient-physician communication.

Health literacy of older adults with musculoskeletal problems: A systematic review

INTRODUCTION

People with poor Health Literacy (HL) find it difficult to understand medical information in their daily lives, participate in health-related decision making and comply with medical instructions. The physical effects of ageing on the musculoskeletal system have a direct impact on skills related to the management of health problems. Many older adults have limited HL, which impacts their ability to fully engage in their care and their health status. The aim of this study is to conduct a systematic review of the published research regarding the prevalence of low HL and its impact on health outcomes of older adults with musculoskeletal problems.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, this review examined all peer-reviewed studies published in English, with specific pre-selected eligibility criteria.

RESULTS

The combined searches yielded 1617 records of which 19 articles were eligible for inclusion. The percentage of low HL varied across the studies of this review, ranging from 14% to 67%. In most studies, however, patients with limited HL were about 1/3 of the participants. Patients of lower educational level, male gender, older age, lower income, unemployment and different country of origin had lower HL level. Low HL was also associated with worse health outcomes, especially adherence to treatment, pain, functionality and health status.

DISCUSSION

It is of major importance to conduct educational interventions aimed at enhancing HL in this patient group, as these will contribute to the empowerment and the promotion of appropriate health behaviors of these patients.

Limited Health Literacy Among Patients With Orthopedic Injuries: A Cross-sectional Survey of Patients Who Underwent Orthopedic Trauma Surgery in a County Hospital Setting

BACKGROUND

Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes.

MATERIALS AND METHODS

This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores.

RESULTS

Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively).

CONCLUSION

Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 2024;47(4):249-255.].

A clinical risk score enables early prediction of dissatisfaction 1 year after total knee arthroplasty

PURPOSE

Dissatisfaction after total knee arthroplasty (TKA) is a prevalent and clinically relevant problem that affects approximately 10%-20% of patients. The aim of this study is to identify factors associated with dissatisfaction 1 year after TKA.

METHODS

A total of 236 patients undergoing TKA were included in this prospective cohort study. Demographic data, preoperative clinical parameters (e.g., axial alignment, osteoarthritis severity) and patient-reported outcome measures (PROMs) were collected preoperatively, at 1 month and 1 year after TKA, encompassing the Knee Society Score (KSS) and Knee injury and Osteoarthritis Outcome Score (KOOS). The primary outcome was dissatisfaction 1 year after TKA, defined as ≤20 points on the KSS satisfaction scale. A risk score based on multiple regression and area under the curve (AUC) analyses was calculated to predict dissatisfaction.

RESULTS

One year after TKA, 16% of the patients were dissatisfied. Dissatisfied patients were significantly younger (p = 0.023) and had a higher body mass index (BMI) (p = 0.007). No differences were observed in preoperative objective (p = 0.903) and functional KSS (p = 0.346), pain (p = 0.306), osteoarthritis severity (p = 0.358), axial knee alignment (p = 0.984) or psychological distress (p = 0.138). The likelihood of dissatisfaction at 1 year was 3.0, 4.0, 7.4, 4.3 and 2.8 times higher amongst patients aged <63.5 years, with a BMI > 30.1 kg/m2, a KOOSPain < 50%, a KSSFunction < 42 points and a KSSExpectation < 9 points (all at 1 month), respectively. Using these variables, a risk score with a maximum of 7 points was developed, demonstrating a high predictive value for dissatisfaction (AUC: 0.792 [95% confidence interval: 0.700-0.884], p < 0.001).

CONCLUSION

Dissatisfaction 1 year after TKA can be predicted by a weighted risk score that includes patient age, BMI, pain, subjective functionality and unmet expectation 1 month postoperatively. Using the risk score, early detection of dissatisfaction has the potential to enable targeted interventions and improve patients' quality of life.

LEVEL OF EVIDENCE

Level II, Prognostic study.

Influence of health literacy on health-related quality of life after total hip arthroplasty

INTRODUCTION

Personal knowledge about the own disease, a key component of health literacy (HL), may have a considerable impact on treatment outcomes. The purpose of this study was to investigate whether the patients' knowledge about the surgical procedure, risks, and aftercare, as well as the satisfaction with the preoperative level of information, has an influence on the health-related quality of life (HRQoL) after primary total hip arthroplasty (THA).

MATERIALS AND METHODS

A total of 176 patients (68.3 ± 10.3 years, 60.8% female) were evaluated. HRQoL was assessed prior to surgery as well as one and twelve months after THA using the 12-item Short Form Questionnaire. Following standardized surgical informed consent, HL was assessed preoperatively using a self-constructed quiz score, while information satisfaction was measured with a single-item rating scale. Sociodemographic and clinical characteristics, including pain (VAS), functionality (WOMAC), and psychological distress (PHQ-4), were also assessed at baseline. Multiple linear regression analyses were performed to examine whether HL, satisfaction with information, age, social class, WOMAC, VAS, and PHQ-4 predict HRQoL at one and twelve months post-surgery.

RESULTS

The average HL quiz score was 23 ± 5.1 out of a possible 33 points. Social class index significantly influenced HL (p < 0.001). A weak correlation between HL and age (r = 0.23, p = 0.01) and no correlation between HL and psychological distress (p = 0.868) were observed. One month after THA, physical HRQoL was significantly predicted by the WOMAC index (p = 0.031) and subjective satisfaction with information (p = 0.022), but not by HL. After twelve months, only the WOMAC was a significant predictor (p < 0.001) of physical HRQoL.

CONCLUSION

Although subjective satisfaction with the patient's preoperative level of information had a significant effect on the physical HRQoL at one month after THA, the influence of osteoarthritis severity outweighed this effect after twelve months. HL had no direct influence on HRQoL. These results suggest that patient satisfaction, rather than knowledge, predicts HRQoL.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Supporting patients to prepare for total knee replacement: Evidence-, theory- and person-based development of a 'Virtual Knee School' digital intervention

INTRODUCTION

Digital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.

OBJECTIVE

To develop a pre-operative TKR education and prehabilitation digital intervention, the 'Virtual Knee School' (VKS).

METHODS

The VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).

RESULTS

Most participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend: 1. Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats. 2. Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.

CONCLUSIONS

Integrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

Evaluating the Role and Impact of Health Literacy for Patients Undergoing Knee Surgery

Health literacy is defined as "the capacity to obtain, process, and understand basic medical information and services and the competence to use such information and services to enhance health." Much of the research regarding health literacy in orthopaedic surgery has focused on readability of educational materials. However, the role of health literacy in patient-reported outcomes is somewhat unknown. The purpose of this review was to evaluate the body of literature pertaining to health literacy and knee surgery outcomes. A literature search was performed using keywords and MeSH terms in PubMed/MEDLINE, Scopus, PsycINFO, SPORTDiscus, and Cochrane. Articles written between 1990 and 2021 were evaluated for inclusion. The title and abstract of all studies returned in each database search were screened. In the case that these did not provide sufficient information, the full-text article was reviewed. The initial database search returned a total of 974 articles for review. Eight of these were duplicate results, and one article had been retracted after publication, leaving a total of 965 to be screened for inclusion. Ninety-six articles remained after screening titles and abstracts for relevance. After applying inclusion criteria, six articles remained and were included in this review. It is clear that health literacy impacts patient outcomes in health care and this review suggests that general and musculoskeletal health literacy affect patient expectations, outcomes, and satisfaction before and after knee surgery. However, the peer-reviewed literature on this topic is still deficient in terms of determining effective methods for addressing this barrier to optimal patient care. Research should focus on further elucidation of the relationships among health literacy, readability, and patient education for optimizing patient outcomes and satisfaction across orthopaedic subspecialties.

"Where is the spleen? Where are the lungs?"-An investigation of the level of anatomical knowledge of the Hong Kong public

This article investigates the level of anatomical knowledge of the Hong Kong public and uses the data to help suggest public engagement activities and health campaigns to raise health literacy in the general population. In the annual public engagement event organized by the University of Hong Kong, 250 attendees took a survey assessing basic anatomical knowledge by putting organs/structures in their correct positions. Description analysis, correlation analysis, independent sample t-test, and one-way ANOVA analysis were conducted by SPSS 27.0. Overall, a mean score of 6.5 out of 20 was achieved. Differences between various demographic parameters were analyzed, and the results showed that better performance on the survey was associated with younger age, higher educational levels, and having healthcare experience. There was also a statistically significant difference in correctly positioning the thyroid between males and females. Interestingly, some misconceptions were thought to arise from the bespoke use of the Chinese language in the survey. The data reflected room for improvement in the level of anatomical knowledge among the public, notably in the older age groups. This was attributed partially to a lack of public outreach initiatives and established anatomy-focused programs, which has restricted public exposure to anatomical knowledge and hindered the development of anatomical sciences in Hong Kong. In conclusion, the knowledge of the public on the human body needs to be improved and possible solutions to improve public awareness of health were raised.

Prevalence of and factors associated with limited health literacy in spine patients

BACKGROUND

Limited health literacy exacerbates health inequity and has serious implications for patient care. It hinders successful communication and comprehension of relevant health information, which can lead to suboptimal care. Despite the evidence regarding the significance of health literacy, the topic has received little consideration in orthopedic spine patients.

PURPOSE

To investigate the prevalence of and factors associated with limited health literacy among outpatients presenting to a tertiary urban academic hospital-based orthopedic spine center.

STUDY DESIGN

Cross-sectionals.

PATIENT SAMPLE

Patients 18 years of age or older seen at a tertiary urban academic hospital-based multi-surgeon outpatient spine center.

OUTCOME MEASURES

The Newest Vital Sign (NVS) health literacy assessment.

METHODS

Between December 2021 and March 2022, 447 consecutive English-speaking patients over the age of 18 years and new to the outpatient spine clinic were approached for participation in a cross-sectional survey study, of which 405 agreed to participate. Patients completed the Newest Vital Sign (NVS) health literacy assessment tool, the Rapid Estimation of Adult Literacy in Medicine Short Form (REALM-SF), and a sociodemographic survey (including race/ethnicity, level of education, employment status, income, and marital status). The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. REALM-SF scores were classified into reading levels below ninth grade (0-6) or at least ninth grade (7). Additional demographic data was extracted from patient records. Online mapping tools were used to collect the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI) for each patient. Subsequently, multivariable regression modeling was performed to identify independent factors associated with limited health literacy.

RESULTS

The prevalence of limited health literacy in patients presenting to an urban academic outpatient spine center was 33% (135/405). Unadjusted analysis found that patients who were socioeconomically disadvantaged (eg, unemployed, lower household income, publicly insured and higher SVI) and had more unfavorable social determinant of health features (eg, housing concerns, higher ADI, less years of education, below ninth grade reading level, unmarried) had high rates of limited health literacy. Adjusted regression analysis demonstrated that limited health literacy was independently associated with higher ADI state decile, living less than 10 years at current address, having housing concerns, not being employed, non-native English speaking, having less years of education and below ninth grade reading level.

CONCLUSIONS

This study found that a substantial portion of the patients presenting to an outpatient spine center have limited health literacy, more so if they are socially disadvantaged. Future efforts should investigate the impact of limited health literacy on access to care, treatment outcomes and health care utilization in orthopedic patients. Neighborhood social vulnerability measures may be a feasible way to identify patients at risk of limited health literacy in clinical practice and offer opportunities for tailored patient care. This may contribute to prioritizing the mitigation of disparities and aid in the development of meaningful interventions to improve health equity in orthopedics.

Health Literacy in Orthopedic Surgery: A Systematic Review

Background: Limited health literacy has been associated with adverse health outcomes. Undergoing orthopedic surgery often requires patients to make complex decisions and adhere to complicated instructions, suggesting that health literacy skills might have a profound impact on orthopedic surgery outcomes. Purpose: We sought to review the literature for studies investigating the level of health literacy in patients undergoing orthopedic surgery and also to assess how those studies report factors affecting health equity. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library for all health literacy studies published in the orthopedic surgery literature up to February 8, 2022. Search terms included synonyms for health literacy and for all orthopedic surgery subspecialties. Two reviewers independently extracted study data in addition to indicators of equity reporting using the PROGRESS+ checklist (Place of Residence, Race/Ethnicity, Occupation, Gender/sex, Religion, Education, Social capital, Socioeconomic status, plus age, disability, and sexual orientation). Results: The search resulted in 616 studies; 9 studies remained after exclusion criteria were applied. Most studies were of arthroplasty (4/9; 44%) or trauma (3/9; 33%) patients. Validated health literacy assessments were used in 4 of the included studies, and only 3 studies reported the rate of limited health literacy in the patients studied, which ranged between 34% and 38.5%. At least one PROGRESS+ item was reported in 88% (8/9) of the studies. Conclusions: We found a paucity of appropriately designed studies that used validated measures of health literacy in the field of orthopedic surgery. The potential impact of health literacy on orthopedic patients and their outcomes has yet to be elucidated. Thoughtful, high-quality trials across diverse demographics and geographies are warranted.

Mobile-Bearing has no Benefit Over Fixed-Bearing Total Knee Arthroplasty in Joint Awareness and Crepitus: A Randomized Controlled Trial

BACKGROUND

Given higher component conformity, rotational availability of polyethylene insert, and more physiologic patellofemoral tracking, mobile-bearing (MB) total knee arthroplasty (TKA) is supposed to offer advantages in joint perception and crepitus. The purpose of this study was to investigate whether MB TKA offers superior outcomes over fixed-bearing (FB) TKA in terms of joint awareness and crepitus.

METHODS

This prospective, randomized, controlled trial included 49 FB and 49 MB TKAs that shared the same posterior-stabilized femoral component. Primary outcomes included joint awareness assessed with the Forgotten Joint Score and crepitus graded according to severity and sound at 3 years postoperatively. Secondary outcomes were the range of motion, the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, component position, and joint line level on radiographs.

RESULTS

The Forgotten Joint Score showed no significant difference between the FB (67 points; range, 0-100) and MB groups (63 points; range, 13-100) (P = .440). For crepitus, no significant differences were found in the overall incidence rate (FB group, 18%; MB group, 12%; P = .386) and grade (grade 1, 6 versus 5; grade 2, 2 versus 1; grade 3, 1 versus 0, respectively). There were no significant differences in range of motion, Knee Society Score, and Western Ontario and McMaster Universities Osteoarthritis Index, as well as radiographic outcomes between the two groups (all, P > .05).

CONCLUSION

MB TKA offers no benefits in terms of joint awareness and crepitus compared with FB TKA at mean 3 years postoperatively. The theoretical advantages of MB TKA have yet to be demonstrated in practice, leaving the selection of bearing type to the surgeon's judgment.

LEVEL OF EVIDENCE

Level II.

Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty

BACKGROUND

Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.

METHODS

We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.

RESULTS

Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).

CONCLUSION

LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.

Social Determinants of Health Disparities are Associated with Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR).

METHODS

A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR.

RESULTS

58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001).

CONCLUSIONS

The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Influences of decision preferences and health literacy on temporomandibular disorder treatment outcome

Background

Shared decision-making is defined as the process by which physicians and informed patients make a shared medical decision, taking into account the preferences and values of the patients. It is well known that shared decision-making practices improve both clinicians’ and patients’ satisfaction and lead to better treatment outcomes. The aim of the study was to assess associations between patients’ roles in decision-making, health literacy levels, and treatment outcomes of temporomandibular disorders (TMDs).

Methods

In total, 131 participants were enrolled. Participants underwent interview and physical examination at baseline and six months after TMD management. TMD was diagnosed according to Diagnostic Criteria/TMD criteria. Myofascial trigger points were bilaterally evaluated in the two masticatory muscles including the temporalis and masseter muscles. The roles that participants preferred to play or had perceived during decision-making and their health literacy levels were assessed using Control Preferences Scale and Newest Vital Sign, respectively.

Results

Participants who perceived themselves as occupying active roles in decision-making showed higher health literacy levels than those with passive perceived roles. Participants with appropriate health literacy showed higher perceived participation levels in decision-making than did those with limited health literacy. The extent of subjective symptomatic improvement after six months of treatment showed significant associations with perceived role in decision-making, despite lack of significant relationships between perceived role in decision-making and the extent of improvement of objective parameters.

Conclusion

Active participation of patients in decision-making improves the satisfaction but limited health literacy constitutes barriers to effective patient engagement during TMD management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02420-x.

Caring for Diverse and High-Risk Patients: Surgeon, Health System, and Patient Integration

Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color. Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color. Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health. High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care. We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.