Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Preoperative predictors of two-year satisfaction in hand and wrist surgery patients

Purpose

As stakeholders seek to improve patient outcomes while maintaining cost-effectiveness in an increasingly expensive healthcare system, metrics such as patient satisfaction are becoming more important. This present study sought to identify factors associated with and independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Methods

Patients undergoing hand and wrist surgery at an urban outpatient institution were enrolled preoperatively into a surgical registry and assessed two years postoperatively. Patient satisfaction with surgery was measured at two years postoperatively with the Surgical Satisfaction Questionnaire (SSQ-8). Bivariate analysis determined associations between postoperative satisfaction and patient demographics, injury specifiers, medical history, and multiple patient-reported outcomes (PROs). Multivariable analysis determined independent predictors of two-year postoperative satisfaction following hand and wrist surgery.

Results

Better surgical satisfaction was associated with having never smoked, no preoperative opioid use, lack of an accompanying legal claim, lack of a workers compensation claim, no clinical history of depression/anxiety, less comorbidities, and higher preoperative expectations.Various PROs relating to function, pain, activity, and general health at both baseline and two years demonstrated associations with postoperative satisfaction. Multivariable analysis confirmed that never smoking, lack of a legal claim, and better preoperative Brief Michigan Hand Questionnaire scores were independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Conclusion

At two years following hand and wrist surgery, better patient satisfaction was best predicted by never smoking, no related legal claim, and better baseline Brief Michigan Hand Questionnaire scores.

Level of evidence

III.

A 23-year analysis of litigation in orthopedic elbow surgery

BACKGROUND

The reasons for malpractice litigation in elbow surgery are not well understood. The aim of this study is to report the most frequently litigated surgeries of the elbow and analyze the reasons for litigation and case outcomes.

METHODS

A retrospective review of the Westlaw legal database was performed, and all federal and state jurisdiction litigation cases involving the elbow from 2000 to 2023 were queried. Cases were excluded if they did not involve an orthopedic surgeon, nor primary elbow injury or procedure. Cases were reviewed for demographic information, surgical procedure based on reference Current Procedural Terminology codes, complications, symptoms, and reasons for litigation. Quantitative information, including settlement and indemnity cost to the defendant orthopedic surgeon, was analyzed. Cases were subdivided based on United States Census Bureau regions and states to assess regional frequency of litigation with analyses of variance.

RESULTS

There were 59 cases meeting inclusion criteria from 2000 to 2023. The most litigated cases involved were ulnar nerve transposition/release and open reduction and internal fixation of the proximal radius and/or ulna at the elbow. The most litigated complication was claimed nerve damage (46%) and permanent disability (27%). Of the total cases, the most frequently litigated symptoms were nerve damage (46%) and loss of function (37%), whereas the least frequent was postoperative stiffness (2%). The Pacific region demonstrated the highest litigation rate (20%), whereas the East South Central, Mountain, and New England regions had the lowest litigation rate (3% each). A favorable verdict was given to the defendant orthopedic surgeon in 59% of the cases. The average loss incurred through settlement was $245,590, whereas the average indemnity paid through verdict was $523,334.

CONCLUSION

Operative fixation of the proximal ulna/radius and ulnar nerve release/transposition are the most litigated procedures of the elbow. Litigation is most associated with nerve injury. Across Census Bureau regions, there is no significant difference in monetary cost incurred through settlements and verdict losses. Although a majority of litigated cases are won by the defending orthopedic surgeon, thorough informed consent and perioperative expectation management may mitigate litigation risk.

How Minimal Clinically Important Difference and Patient Acceptable Symptom State Relate to Patient Expectations and Satisfaction in Spine Surgery: A Review

This narrative review seeks to enhance our comprehension of how Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) values in established Patient Reported Outcome Measures (PROMs) for spine surgery correspond with patient preoperative expectations and postoperative satisfaction. Through our literature search, we found that both MCID and PASS serve as dependable indicators of patient expectations. However, MCID may be more susceptible to a floor effect. This implies that PASS may offer a more accurate reflection of how patients anticipate surgery to address their symptoms. Nevertheless, it is crucial to recognize that achieving MCID or PASS may not be an absolute prerequisite for patients to be satisfied with their treatment.

Robotic assisted Total Knee Arthroplasty (TKA) is not associated with increased patient satisfaction: a systematic review and meta-analysis

PURPOSE

Total knee arthroplasty (TKA) is a common orthopedic surgery, yet postoperative dissatisfaction persists in around 20% of cases. Robotic total knee arthroplasty (rTKA) promises enhanced precision, but its impact on patient satisfaction compared to conventional TKA remains controversial (cTKA). This systematic review aims to evaluate patient satisfaction post-rTKA and compare outcomes with cTKA.

METHODS

Papers from the following databases were identified and reviewed: PubMed, Scopus, Web of Science, and the Cochrane Online Library, using keywords like "Knee replacement," "Total knee arthroplasty," "Robotic," and "Patient satisfaction." Extracted data included patient satisfaction measures, Knee Society Score, Oxford Knee Score, Forgotten Joint Score, SF-36, HSS, and KOOS. Statistical analysis, including odds ratio and 95% CI was performed using R software. Heterogeneity was assessed using Cochrane's Q test.

RESULTS

The systematic review included 17 articles, involving 1148 patients (571 in the rTKA group and 577 in the cTKA group) assessing patient satisfaction following rTKA. An analysis of proportions reveals rTKA satisfaction rate was 95%, while for cTKA, it was 91%. A meta-analysis comparing rTKA and cTKA found no statistically significant difference in patient satisfaction. Additionally, various patient-reported outcome measures (PROMs) were examined, showing mixed results across different studies and follow-up periods.

CONCLUSIONS

The results of this study found no difference in patient satisfaction outcomes in the short to mid-term for rTKA compared to conventional methods. This study does not assert superiority for the robotic approach, highlighting the need for careful consideration of various factors influencing outcomes in knee arthroplasty.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

BACKGROUND

Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication.

METHODS

In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses.

RESULTS

The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04).

CONCLUSIONS

These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce.

CLINICAL RELEVANCE

This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

What are our patients asking Google about acromioclavicular joint injuries?-frequently asked online questions and the quality of online resources

Background

Management of acromioclavicular (AC) joint injuries has been an ongoing source of debate, with over 150 variations of surgery described in the literature. Without a consensus on surgical technique, patients are seeking answers to common questions through internet resources. This study investigates the most common online patient questions pertaining to AC joint injuries and the quality of the websites providing information.

Hypothesis

1) Question topics will pertain to surgical indications, pain management, and success of surgery and 2) the quality and transparency of online information are largely heterogenous.

Methods

Three AC joint search queries were entered into the Google Web Search. Questions under the "People also ask" tab were expanded in order and 100 results for each query were included (300 total). Questions were categorized based on Rothwell's classification. Websites were categorized by source. Website quality was evaluated by the Journal of the American Medical Association (JAMA) Benchmark Criteria.

Results

Most questions fell into the Rothwell Fact category (48.0%). The most common question topics were surgical indications (28.0%), timeline of recovery (13.0%), and diagnosis/evaluation (12.0%). The least common question topics were anatomy/function (3.3%), evaluation of surgery (3.3%), injury comparison (1.0%), and cost (1.0%). The most common websites were medical practice (44.0%), academic (22.3%), and single surgeon personal (12.3%). The average JAMA score for all websites was 1.0 ± 1.3. Government websites had the highest JAMA score (4.0 ± 0.0) and constituted 45.8% of all websites with a score of 4/4. PubMed articles constituted 63.6% (7/11) of government website. Comparatively, medical practice websites had the lowest JAMA score (0.3 ± 0.7, range [0-3]).

Conclusion

Online patient AC joint injury questions pertain to surgical indications, timeline of recovery, and diagnosis/evaluation. Government websites and PubMed articles provide the highest-quality sources of reliable, up-to-date information but constitute the smallest proportion of resources. In contrast, medical practice represents the most visited websites, however, recorded the lowest quality score. Physicians should utilize this information to answer frequently asked questions, guide patient expectations, and help provide and identify reliable online resources.

What are our patients asking google about posterior cruciate ligament injuries? - frequently asked online questions and quality of online resources

OBJECTIVES

This study investigates the most common online patient questions pertaining to posterior cruciate ligament (PCL) injuries and the quality of the websites providing information.

METHODS

Four PCL search queries were entered into the Google Web Search. Questions under the 'People also ask' tab were expanded in order and 100 results for each query were included (400 total). Questions were categorized based on Rothwell's Classification of Questions (Fact, Policy, Value). Websites were categorized by source (Academic, Commercial, Government, Medical Practice, Single Surgeon Personal, Social Media). Website quality was evaluated based on the Journal of the American Medical Association (JAMA) Benchmark Criteria. Pearson's chi-squared was used to assess categorical data. Cohen's kappa was used to assess inter-rater reliability.

RESULTS

Most questions fell into the Rothwell Fact category (54.3%). The most common question topics were Diagnosis/Evaluation (18.0%), Indications/Management (15.5%), and Timeline of Recovery (15.3%). The least common question topics were Technical Details of Procedure (1.5%), Cost (0.5%), and Longevity (0.5%). The most common websites were Medical Practice (31.8%) and Commercial (24.3%), while the least common were Government (8.5%) and Social Media (1.5%). The average JAMA score for websites was 1.49 ± 1.36. Government websites had the highest JAMA score (3.00 ± 1.26) and constituted 42.5% of all websites with a score of 4/4. Comparatively, Single Surgeon Personal websites had the lowest JAMA score (0.76 ± 0.87, range [0-2]). PubMed articles constituted 70.6% (24/34) of Government websites, 70.8% (17/24) had a JAMA score of 4 and 20.8% (5/24) had a score of 3.

CONCLUSION

Patients search the internet for information regarding diagnosis, treatment, and recovery of PCL injuries and are less interested in the details of the procedure, cost, and longevity of treatment. The low JAMA score reflects the heterogenous quality and transparency of online information. Physicians can use this information to help guide patient expectations pre- and post-operatively.

Evaluation of Patient Expectations and Outcomes after Distal Radius Fractures

BACKGROUND

Patient expectations influence patient-reported outcomes after musculoskeletal injuries. The goal of this study is to determine how pretreatment expectations correlate with outcomes in patients with distal radius fractures.

METHODS

Seventy-five patients with an isolated distal radius fracture were prospectively enrolled into nonoperative and operative cohorts. The Trauma Expectation Factor-Trauma Outcome Measure (TEF-TOM) score was the primary outcome measure. Trauma Expectation Factor scores were recorded at the time of enrollment, and TOM scores were recorded at 3, 6, and 12 months. Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) and Patient-Rated Wrist Evaluation (PRWE) scores were also recorded.

RESULTS

Trauma Outcome Measure scores at all time points were worse than expected (P < .01). Expectations were higher for patients younger than 65 years than for the 65+ group (P = .02). In patients aged 65+ years, mean TOM at 3 months was not significantly different than expected (P = .11) but decreased by 6 (P = .04) and 12 months (P < .01). Baseline TEF and TEF-TOM scores were not significantly different between operative and nonoperative groups (P = .37). Quick Disabilities of the Arm, Shoulder, and Hand and PRWE scores were not significantly different between age or treatment groups at the final follow-up.

CONCLUSIONS

The overall treatment of distal radial injuries in our study did not meet patient expectations. Patients aged 65 years or older had lower expectations but were not able to predict their outcomes better than patients aged <65 years. There were no differences in TEF or TOM by treatment method. Patients demonstrated improved functional outcomes (qDASH/PRWE) at all time points regardless of age and treatment method.

The association of early response with the outcome of psychosomatic rehabilitation in patients with mental disorders and its link to treatment and illness beliefs-A prospective longitudinal cohort study

Early response is considered to be an important predictor for therapy outcomes; yet little is known about its relevance in psychosomatic rehabilitation. This paper aims to describe the association of early response in psychosomatic rehabilitation, as well as the associations of early response with pre-rehabilitative factors such as illness and treatment beliefs.

A longitudinal study with three measurement points was applied. Early response was defined using the percent improvement method after two weeks of treatment. Its association with therapy outcome and with illness and treatment beliefs was analyzed using multiple regression analyses.

A total of 264 participants took part. Early response was a significant predictor of psychosomatic rehabilitation outcome, explaining an incremental variance of 1-30% after controlling for initial symptom burden. Illness and treatment beliefs predicted 6-20% variance in early response. Important illness beliefs referred to perceived symptoms, consequences and comprehensibility of the illness. Important treatment beliefs referred to expectations about rehabilitation structure, processes and concerns.

Early response is associated with the therapy outcome of psychosomatic rehabilitation, with illness and treatment beliefs found to be associated with early response. Further research on the predictors of early response in psychosomatic rehabilitation is needed.

Algorithm Versus Expert: Machine Learning Versus Surgeon-Predicted Symptom Improvement After Carpal Tunnel Release

BACKGROUND AND OBJECTIVES

Surgeons rely on clinical experience when making predictions about treatment effects. Incorporating algorithm-based predictions of symptom improvement after carpal tunnel release (CTR) could support medical decision-making. However, these algorithm-based predictions need to outperform predictions made by surgeons to add value. We compared predictions of a validated prediction model for symptom improvement after CTR with predictions made by surgeons.

METHODS

This cohort study included 97 patients scheduled for CTR. Preoperatively, surgeons estimated each patient's probability of improvement 6 months after surgery, defined as reaching the minimally clinically important difference on the Boston Carpal Tunnel Syndrome Symptom Severity Score. We assessed model and surgeon performance using calibration (calibration belts), discrimination (area under the curve [AUC]), sensitivity, and specificity. In addition, we assessed the net benefit of decision-making based on the prediction model's estimates vs the surgeon's judgement.

RESULTS

The surgeon predictions had poor calibration and suboptimal discrimination (AUC 0.62, 95%-CI 0.49-0.74), while the prediction model showed good calibration and appropriate discrimination (AUC 0.77, 95%-CI 0.66-0.89, P = .05). The accuracy of surgeon predictions was 0.65 (95%-CI 0.37-0.78) vs 0.78 (95%-CI 0.67-0.89) for the prediction model ( P = .03). The sensitivity of surgeon predictions and the prediction model was 0.72 (95%-CI 0.15-0.96) and 0.85 (95%-CI 0.62-0.97), respectively ( P = .04). The specificity of the surgeon predictions was similar to the model's specificity ( P = .25). The net benefit analysis showed better decision-making based on the prediction model compared with the surgeons' decision-making (ie, more correctly predicted improvements and/or fewer incorrectly predicted improvements).

CONCLUSION

The prediction model outperformed surgeon predictions of improvement after CTR in terms of calibration, accuracy, and sensitivity. Furthermore, the net benefit analysis indicated that using the prediction model instead of relying solely on surgeon decision-making increases the number of patients who will improve after CTR, without increasing the number of unnecessary surgeries.

Patient Likelihood to Repeat Surgery After Highly "Successful" Hand Procedures

BACKGROUND

Outcomes for routine hand procedures, such as carpal tunnel release, trigger finger release, and first dorsal compartment release, are typically reported as "highly successful" with "infrequent complications" based on classic literature. No contemporary study has utilized a large prospective registry to assess patient willingness to repeat surgery. We utilized a prospective hand registry to evaluate the proportion of patients that would repeat surgery after common hand procedures.

METHODS

We utilized a prospective, hand surgery registry to collect postoperative patient likelihood to repeat surgery in patients undergoing surgery for 9 common hand procedures. All measures were reported at 12, 24, or 52 weeks. We analyzed the percentage of patients that would repeat the procedure for all diagnoses, as well as stratified by the most common 9 isolated diagnoses.

RESULTS

At the time of analysis, 1905 patients met our inclusion criteria. The average percentage of patients across all procedures that would repeat surgery was 81.6%. When stratified by the most common 9 diagnoses the percentage of patients that would repeat surgery ranged from 51.9% (ulnar nerve surgery at the elbow) up to 87.5% (endoscopic carpal tunnel release).

CONCLUSIONS

After undergoing routine hand procedures, a significant percentage of patients would choose not to repeat surgery. Hand surgeons can do better in setting clear and realistic preoperative expectations when counseling patients prior to even routine hand surgeries.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition

PURPOSE

Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied.

METHODS

Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained.

RESULTS

A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT).

CONCLUSIONS

Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Preoperative expectations, postoperative satisfaction and patient directed priorities for clinical burn research

INTRODUCTION

Burn patients receiving split thickness skin grafting are left with scarring and chronically dysfunctional grafted skin. Given evidence that patients' preoperative expectations mediate postoperative outcomes and satisfaction, we described burn patients' experience, expectations, and satisfaction with their skin graft, their views towards a cell based clinical trial to improve their graft and identified graft outcome measures for use in future studies.

METHODS

Data were collected via questionnaires preoperatively, one, and three months postoperatively. Longitudinal analyses assessed change over time.

RESULTS

Expectations of graft function were consistent pre- and postoperatively. Expectations of graft appearance showed significant decrease over time (β1 = -0.290, p = 0.008). Significant improvements in skin function (β1 = 0.579, p = 0.000) and appearance (β1 = 0.247, p = 0.025) at the wound site during recovery were observed. Patients noted great difference between grafted and normal skin. Patient satisfaction with their graft did not change significantly over time. Patients were willing to participate in a cell based clinical trial to improve graft symptomology and prioritized improvements in scarring, redness, sensation, and elasticity.

CONCLUSIONS

Outcome measures in trials advancing skin grafting should reflect chronic, patient prioritized limitations. We recommend preoperative educational interventions for burn patients receiving grafting to improve postoperative satisfaction.

Unlocking the Healing Potential: Cannabinoids in Spine Surgery for Pain Relief and Recovery

» Cannabinoids, such as D9-tetrahydrocannabinol and cannabidiol, interact with endocannabinoid receptors in the central nervous system and immune system, potentially offering pain relief. The entourage effect, resulting from the interaction of multiple cannabis components, may enhance therapeutic impact and efficacy, making them promising candidates for exploring pain relief in spine operations, known to be among the most painful operative procedures.» The use of cannabinoids in pain management requires careful consideration of safety, including their cognitive and psychomotor effects, potential cardiovascular risks, risk of dependence, mental health implications, and drug interactions.» Few studies have analyzed cannabinoid use in relation to spine surgery, with variable results reported, indicating possible effects on reoperation rates, mortality, complications, postoperative opioid use, and length of hospital stay.» Current knowledge gaps exist in the understanding of cannabinoid effects on spine surgery, including the exploration of different administration routes, timing, dosage, and specific outcomes. In addition, mechanistic explanations for the observed results are lacking.» Ethical considerations related to informed consent, medical expertise, societal impact, and legal compliance must also be thoroughly addressed when considering the utilization of cannabinoids in spinal pathologies and back pain treatment.

Rehabilitation Phases, Precautions, and Mobility Goals Following Total Hip Arthroplasty

The prevalence of total hip arthroplasty (THA) for advanced hip osteoarthritis (OA) is both increasing and shifting toward a younger average age. However, THA alone does not typically normalize function in these patients. Postoperative rehabilitation is often recommended to optimize joint motion, strength, and function. To date, there are no peer-reviewed clinical practice guidelines for postoperative rehabilitation following THA. Thus, optimal postoperative rehabilitation requires consideration of the existing literature and clinical expertise. This review article summarizes current recommendations for postoperative management of THA, including phases of rehabilitation, postoperative hip precautions, the effect of rehabilitation setting and mode of delivery on postoperative outcomes, and gait mechanics.

Patient Perceptions of Wearable and Smartphone Technologies for Remote Outcome Monitoring in Total Knee Arthroplasties

While there is enthusiasm for wearables and smartphone technologies in evaluating clinical outcomes among clinicians, less is known about the willingness of patients who have osteoarthritis (OA) to consent for remote outcome monitoring. We developed an Institutional Review Board-approved questionnaire to assess patient perceptions of remote monitoring technologies in a high-volume orthopaedic clinical center. Fifty total knee arthroplasty (TKA) patients (56% female; mean age: 61 years, range: 23-89) and fifty nonoperative OA knee patients (54% female; mean age: 58 years, range: 25-89) routinely consulted in the clinic as part of their OA treatment and consented to participate in the study. Patient perceptions were compared using Pearson's chi-square analyses with a significance threshold of p < 0.05. We found that TKA patients were more receptive to the use of smartphone apps (84 vs. 60%, p = 0.008) and wearable sensors (80 vs. 48%, p < 0.001) and learning to use custom wearables (72 vs. 38%, p = 0.002) than nonoperative OA knee patients as part of their treatment. Likewise, the majority of TKA patients were willing to use the global positioning system in their postoperative technology (54 vs. 18%, p < 0.001), especially if they were only active during certain circumstances (62 vs. 24%, p < 0.001). TKA patients also expressed willingness to have their body movement (68%), balance (70%), sleep (76%), and cardiac output (80%) tracked using remote technologies. Overall, we found that TKA patients were highly receptive to using wearable technology in their treatments, whereas nonoperative OA knee patients were generally unreceptive. Our study challenges the concept that current wearable technology approaches will be generally effective as a tool to remotely monitor all patients across the OA severity landscape.

Patient Expectations and Satisfaction in Pediatric Orthopedics

PURPOSE OF REVIEW

The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients.

RECENT FINDINGS

Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Fulfilment of patients' mandatory expectations are crucial for satisfaction: a study amongst 352 patients after total knee arthroplasty (TKA)

PURPOSE

Patient satisfaction with the results of their total knee arthroplasty (TKA) is one of the primary goals of this elective procedure. Furthermore, the association between the fulfilment of patients' expectations and their satisfaction is well known. The aim of this study was to identify the key expectations of patients awaiting a TKA, evaluate their fulfilment, and compare the outcomes between very and not fully satisfied patients.

METHODS

A prospective cohort study of patients with knee OA scheduled for primary TKA was performed. Pre- and one-year postoperatively patient-reported outcome measures (PROMs) were assessed. Expectations and their fulfilment were evaluated via a questionnaire encompassing 31 expectations. Preoperatively, expectations were indicated as mandatory, desirable and not important. Postoperatively, fulfilment was rated as exceeded, fulfilled, partially or not fulfilled, and not applicable. Satisfaction with the results of TKA was measured with a numeric rating scale (NRS) of 0-10. Discrimination between not fully satisfied and very satisfied patients was set at ≥ 8, as has been proposed recently. To identify independent predictors of this discrimination, a multivariate logistic regression analysis was performed.

RESULTS

Complete data sets of 352 patients were analysed. A set of 17 key expectations was identified. Relief of knee pain was fulfilled the most, and improvement of physical function was fulfilled the least. When asked about overall fulfilled expectations, 40% of patients rated them as exceeded, 34% as fulfilled and 26% as less fulfilled than expected. Not fully satisfied patients showed significantly lower PROMs pre- and postoperatively and less fulfilled key expectations. Higher numbers of exceeded and fulfilled mandatory expectations, higher overall fulfilment and better range of motion (ROM) were significant predictors for satisfaction ≥ 8.

CONCLUSION

Patients' expectations of TKA outcomes were high with equal emphasis on knee-related and general health-related aspects. Their fulfilment was positively associated with satisfaction. Surgeons should ask patients about mandatory expectations for successful TKA and counsel them about the likelihood of their fulfilment to avoid unrealistic expectations.

LEVEL OF EVIDENCE

II.

Patient preferences as human factors for health data recommender systems and shared decision making in orthopaedic practice

Background

A core set of requirements for designing AI-based Health Recommender Systems (HRS) is a thorough understanding of human factors in a decision-making process. Patient preferences regarding treatment outcomes can be one important human factor. For orthopaedic medicine, limited communication may occur between a patient and a provider during the short duration of a clinical visit, limiting the opportunity for the patient to express treatment outcome preferences (TOP). This may occur despite patient preferences having a significant impact on achieving patient satisfaction, shared decision making and treatment success. Inclusion of patient preferences during patient intake and/or during the early phases of patient contact and information gathering can lead to better treatment recommendations.

Aim

We aim to explore patient treatment outcome preferences as significant human factors in treatment decision making in orthopedics. The goal of this research is to design, build, and test an app that collects baseline TOPs across orthopaedic outcomes and reports this information to providers during a clinical visit. This data may also be used to inform the design of HRSs for orthopaedic treatment decision making.

Methods

We created a mobile app to collect TOPs using a direct weighting (DW) technique. We used a mixed methods approach to pilot test the app with 23 first-time orthopaedic visit patients presenting with joint pain and/or function deficiency by presenting the app for utilization and conducting qualitative interviews and quantitative surveys post utilization.

Results

The study validated five core TOP domains, with most users dividing their 100-point DW allocation across 1-3 domains. The tool received moderate to high usability scores. Thematic analysis of patient interviews provides insights into TOPs that are important to patients, how they can be communicated effectively, and incorporated into a clinical visit with meaningful patient-provider communication that leads to shared decision making.

Conclusion

Patient TOPs may be important human factors to consider in determining treatment options that may be helpful for automating patient treatment recommendations. We conclude that inclusion of patient TOPs to inform the design of HRSs results in creating more robust patient treatment profiles in the EHR thus enhancing opportunities for treatment recommendations and future AI applications.

[Translated article] Translation, validation, and cultural adaptation of the HSS-ES scale (Hospital for Special Surgery's [HSS] Shoulder Surgery Expectations Survey)

INTRODUCTION

The questionnaire Hospital for Special Surgery Shoulder Surgery Expectations Survey (HSS-ES) is a tool used to assess the preoperative expectations of patients with shoulder pathologies. The purpose of this study is to translate, culturally adapt, and validate the Spanish version of the HSS-ES questionnaire to assess preoperative expectations in Spanish-speaking patients.

METHODOLOGY

Questionnaire validation study, using a structured method where a survey-type tool was processed, evaluated and validated. The study involved 70 patients from the shoulder surgery outpatient clinic of a tertiary care hospital, with shoulder pathologies requiring surgery.

RESULTS

The version of the questionnaire translated into Spanish presented a very good internal consistency with a Cronbach's Alpha of 0.94 and a very good reproducibility with an Intraclass Correlation Coefficient (ICC) of 0.99.

CONCLUSION

The HSS-ES questionnaire presents an adequate intragroup validation and a strong intergroup correlation according to the internal consistency analysis of the questionnaire and the ICC. Therefore, it is considered an adequate questionnaire to use in the Spanish-speaking population.

Does Symptom Duration Prior to Anterior Cervical Discectomy and Fusion for Disc Herniation Influence Patient-Reported Outcomes in a Workers' Compensation Population?

OBJECTIVE

To evaluate the influence of symptom duration before anterior cervical discectomy and fusion (ACDF) on patient-reported outcomes (PROs) in workers' compensation patients.

METHODS

A prospective registry was searched for workers' compensation patients who underwent ACDF for herniated disc. Two cohorts based on symptom duration were formed: lesser duration (LD) (<6 months) and prolonged duration (PD) (≥6 months). PROs were collected preoperatively and at 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. PROs were compared within and between groups. Rates of minimum clinically important difference (MCID) were compared between groups.

RESULTS

The study included 63 patients. The LD cohort reported improvement in Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Neck Disability Index (NDI), and visual analog scale (VAS) neck at 12 weeks and 6 months and VAS arm at all periods (all P ≤ 0.036). The LD cohort reported improvement in NDI at 12 weeks and 6 months and VAS arm at 6 weeks, 12 weeks, and 6 months (all P ≤ 0.037). Between groups, the LD cohort demonstrated superior scores in PROMIS-PF at 6 weeks, 12 weeks, and 6 months; NDI preoperatively and at 6 weeks, 12 weeks, and 6 months; VAS neck at 12 weeks; and 9-item Patient Health Questionnaire (PHQ-9) at 6 months (all P ≤ 0.045). The LD group was more likely to achieve MCID in PROMIS-PF at 12 weeks (P = 0.012). The PD group was more likely to achieve MCID in PHQ-9 at 6 months (P = 0.023).

CONCLUSIONS

Regardless of length of symptom duration before ACDF in workers' compensation patients, the patients demonstrated improvements in disability and arm pain. Patients with LD also demonstrated improvements in physical function and neck pain. Patients with LD demonstrated superior scores in physical function, pain, disability, and mental health and were more likely to achieve clinically significant improvement in physical function. Patients with PD were more likely to achieve clinically significant improvement in mental health.

Emerging Need for PROMs to Measure the Impact of Spine Disorders on Overall Health and Well-being: Measuring Expectations as an Example for Lumbar Degenerative Spondylolisthesis

Background: Assessing the impact of spine disorders such as lumbar degenerative spondylolisthesis (LDS) on overall health is a component of quality of care that may not be comprehensively captured by spine-specific and single-attribute patient-reported outcome measures (PROMs). Purpose: We sought to compare PROMs to the Lumbar Surgery Expectations Survey ("Expectations Survey"), which addresses multiple aspects of health and well-being, and to compare the relevance of surgeon-selected versus survey-selected Patient-Reported Outcomes Measurement Information System (PROMIS) items to LDS. Methods: In a cross-sectional study, 379 patients with LDS preoperatively completed the Expectations Survey, Numerical Rating Pain Scales, Oswestry Disability Index (ODI), and PROMIS computer-adaptive physical function, pain, and mental health surveys. Expectations Survey scores were compared to PROMs with correlation coefficients (indicating strengths of relationships) and probability values (indicating associations by chance). Surgeons reviewed physical function questions to identify those particularly relevant to LDS. Results: Patients' mean age was 67 years, 64% were women, and 83% had single-level and 17% had multiple-level LDS. Probability values between the Expectations Survey and PROMs were reliable, but strengths of relationships were only mild to moderate, indicating PROMs did not comprehensively capture the impact of LDS. None of the surgeon-selected PROMIS physical function questions were posed to patients. Conclusion: This cross-sectional study found PROMs to be reliably associated but not strongly correlated with the Expectations Survey, which addresses the whole-patient impact of LDS. New measures that complement PROMIS and ODI should be developed to capture the whole-person effects of LDS and permit attribution of LDS treatments to overall health.

Traumatic rotator cuff tears with concomitant shoulder dislocation: tear characteristics and postsurgical outcomes

BACKGROUND

Arthroscopic rotator cuff repair has been shown to have favorable outcomes following traumatic rotator cuff tear with concomitant shoulder dislocation. The aim of this study was to compare outcomes and tear characteristics between patients who underwent arthroscopic rotator cuff repair following traumatic tear with shoulder dislocation to those without dislocation.

METHODS

A retrospective review of 226 consecutive patients with traumatic rotator cuff tears who underwent arthroscopic repair between 2013 and 2017 with a minimum of 1-year follow-up was performed. Patients with traumatic dislocations and concomitant rotator cuff tears were placed in the Dislocation & Tear cohort (DT cohort) and were matched 1:2 with a second cohort sustaining traumatic cuff tears without dislocation (T cohort). Primary outcomes were injury characteristics including tendon involvement and atrophy and tear size and thickness. Secondary outcomes were postoperative strength and range of motion (ROM) in forward flexion (FF), external rotation (ER), and internal rotation (IR); patient-reported outcomes including Subjective Shoulder Value, visual analog scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; complications including repair failure (defined as symptomatic retear confirmed on postoperative magnetic resonance imaging), infection, adhesive capsulitis, and impingement; and rates of revision surgery.

RESULTS

There were 18 patients in the DT Cohort and 36 patients in the T Cohort with no significant differences in time to final follow-up (50.4 ± 24.5 months vs. 49.0 ± 30.4 months, P = .73). The DT cohort displayed a larger mean tear size (34 ± 12 mm vs. 19 ± 12 mm, P = .01) and had greater infraspinatus involvement (78% vs. 36%, P = .004) and subscapularis involvement (72% vs. 39%, P = .02) than the T cohort. With regard to strength, postoperative ER strength was less likely to be 5/5 in the DT Cohort (53% vs. 94% of patients with 5/5 strength, P = .002) compared with the T cohort. With regard to ROM, the DT cohort had significantly lower preoperative FF (90° ± 55° vs. 149° ± 33°, P < .001), ER (36 ± 21° vs. 52° ± 14°, P = .02), and IR (5.4 ± 2.1 vs. 7.5 ± 1.2, P = .002) compared with the T cohort but had similar FF, ER, and IR outcomes postoperatively. There were no differences between the groups for complications and postoperative patient-reported outcomes.

CONCLUSION

Traumatic rotator cuff tears with concomitant dislocations are associated with larger tear size and greater infraspinatus and subscapularis involvement than traumatic tears without dislocation. Arthroscopic repair of this injury is associated with lower preoperative ROM in FF, ER, and IR, as well as lower postoperative ER strength compared with traumatic tears without dislocation. Nonetheless, excellent patient-reported outcomes can be achieved following arthroscopic repair similar to patients without dislocation.

Fulfillment of Patient Expectations after Acute Respiratory Failure: A Multicenter Prospective Cohort Study

Rationale: Discussion of patient expectations for recovery is a component of intensive care unit (ICU) follow-up clinics. However, few studies have formally evaluated recovery-related expectations of ICU survivors. Objectives: To estimate the prevalence of unmet expectations for recovery 6 months after hospital discharge among adult survivors of acute respiratory failure (ARF). Methods: This was a prospective, longitudinal, cohort study of survivors of ARF discharged to home from five U.S. medical centers. Expectations for functional recovery were assessed by asking which activities and instrumental activities of daily living (I/ADLs) survivors expected to perform independently at 6 months. Survivors' expectations for overall health status were assessed using a visual analogue scale ranging from 0 to 100. At 6-month follow-up, participants reported which I/ADLs they could perform independently and rated their overall health status using a 100-point visual analogue scale. We defined a participant's functional expectations as being met if they reported independently performing I/ADLs as expected at hospital discharge. Health expectations were considered to be met when self-rated health status at 6 months was no more than 8 points lower than expected at enrollment. Results: Among 180 enrollees, 169 (94%) were alive, and 160 of these (95%) participated in 6-month follow-up. Functional expectations were met for 71% of participating survivors, and overall health expectations were met for 50%. Expectations for functional independence were high, ranging from 87% (housekeeping) to 99% (using a telephone). General health expectations were variable (median, 85; interquartile range [IQR], 75-95). At 6-month follow-up, self-rated, overall health ranged from 2 to 100 (median, 80; IQR, 60-85). In exploratory analyses, participants with met versus unmet expectations differed most in formal education (functional expectations standardized difference = 0.88; health expectations standardized difference = 0.41). Conclusions: Expectations of survivors of ARF about independent functioning were high and generally met, but half had unmet general health expectations 6 months after discharge. It is difficult to predict whose health expectations will be unmet, but possessing less formal education may be a risk factor. Clinical trial registered with www.clinicaltrials.gov (NCT03797313).

I'll be back - Predictive validity of adults' expectations for recovery after fractures - A longitudinal observational study

PURPOSE

Recovery after fractures due to accidents relates to all aspects of the biopsychosocial model. Therefore, it is difficult for the patients to foresee the consequences of the fractures. This study aimed to examine 1) patients' expectations regarding the impact of the injury on everyday life, 2) predictive validity of their expectations after six months, and 3) factors that predict a return to work.

PATIENTS AND METHODS

Patients were 18-64 years old and hospitalized with simple or compound/multiple fractures due to an accident. During admission, structured interviews were conducted with a questionnaire covering working conditions, expectations regarding recovery, sports, economy, family, household, and return to work. Additionally, mental and physical status were covered with Short Musculoskeletal Function Assessment questionnaire (SMFA) and Short Form 36, and working conditions were uncovered too. After six months, telephonic interviews were conducted with the 164 available patients to elucidate the impact of the fractures on everyday life, their health status, and sick leave. Likelihood ratios, post-test probabilities, and logistic regression analysis were performed to establish if patients' expectations predicted recovery, economy, sports, family, household, and return to work.

RESULTS

Few patients' baseline expectations about everyday life were met. The likelihood ratios were small, and the post-test probabilities for expectations consistent with outcomes were between 18% and 68%, with recovery as the lowest and participation in sports as the highest. In the multivariate analysis, patients' expectations did not predict short-term (less than two months) or long-term sick leave (more than three months). Self-rated health and the bother index of SMFA were significant short-term and long-term predictors for sick leave. Additionally, vitality, pain, and decision latitude at work predicted sick leave of less than two months.

CONCLUSION

A few days after the accident, patients' expectations about everyday life are not associated with outcomes six months later. Likelihood ratios indicate difficulties for the patients in predicting fractures' consequences on various aspects of everyday life. Return to work was associated with self-rated health and the bother index of SMFA. Future research should examine if fracture patients can benefit from comprehensive, individual counseling during admission to set appropriate expectations.

Parental Caregiver Expectations and Satisfaction Following Hip Reconstruction and Spinal Fusion in Children With Cerebral Palsy

Children with severe (Gross Motor Function Classification System [GMFCS] IV-V) cerebral palsy (CP) exhibit profound physical and developmental impairments and require assistance for all activities of daily living. No curative treatments exist although surgical procedures to correct underlying hip and spine deformities can improve their quality of life. Despite the efficacy of these surgeries, little is known regarding parental caregivers' expectations specific to surgical outcomes and their satisfaction with surgical outcomes. The purpose was to explore parental caregiver expectations and satisfaction with hip and spine surgeries that their children with GMFCS IV-V CP underwent. Variations among preoperative expectations, changes in expectations over time, and the relationship of expectations on caregiver satisfaction were examined. A qualitative descriptive approach with conventional content analysis was utilized. Three preoperative caregiver expectation themes were identified: increasing functionality, increasing comfort, and maintaining health and averting crisis. These themes were still present at 5-year follow-up; however, more caregivers refocused their expectations from improving function to providing palliation. A clear relationship between expectations and caregiver satisfaction, however, was not identified. A deeper understanding surrounding caregiver expectation and satisfaction following surgical procedures is needed.

The Effect of Surgeon and Hospital Volume on Total Hip Arthroplasty Patient-Reported Outcome Measures: An American Joint Replacement Registry Study

BACKGROUND

Some studies have shown lower morbidity and mortality rates with increased surgeon and hospital volumes after total hip arthroplasty (THA). This study sought to determine the relationship between surgeon and hospital volumes and patient-reported outcome measures after THA using American Joint Replacement Registry data.

METHODS

Using American Joint Replacement Registry data from 2012 to 2020, 4,447 primary, elective THAs with both preoperative and 1-year postoperative Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) scores were analyzed. This study was powered to detect the minimum clinically important difference (MCID). The main exposure variables were median annual surgeon and hospital volumes. Tertiles were formed based on the median annual number of THAs conducted: low-volume (1 to 42), medium-volume (42 to 96), and high-volume (≥96) surgeons and low-volume (1 to 201), medium-volume (201 to 392), and high-volume (≥392) hospitals. Mean preoperative and 1-year postoperative HOOS-JR scores were compared.

RESULTS

Preoperative HOOS-JR scores were significantly higher at high-volume hospitals than low-volume and medium-volume hospitals (49.66 ± 15.19 vs. 47.68 ± 15.09 and 48.34 ± 15.22, P < 0.001), although these differences were less than the MCID. At the 1-year follow-up, no difference was noted with no resultant MCID. Preoperative and 1-year HOOS-JR scores did not markedly vary with surgeon volume. In multivariate regression, low-volume and medium-volume surgeons and hospitals had similar odds of MCID achievement in HOOS-JR scores compared with high-volume surgeons and hospitals, respectively.

CONCLUSION

Using the HOOS-JR score as a validated patient-reported outcome measure, higher surgeon or hospital THA volume did not correlate with higher postoperative HOOS-JR scores or greater chances of MCID achievement in HOOS-JR scores compared with medium and lower volume surgeons and hospitals.

Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXT

Preoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis.

PURPOSE

The primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment.

STUDY DESIGN/SETTING

Patients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry.

PATIENT SAMPLE

Patients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included.

OUTCOME MEASURES

The North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year.

METHODS

Expectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression.

RESULTS

Three hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures. Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001]. Postoperative expectations fulfillment did not differ between procedures.

CONCLUSION

Preoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures.

Team Approach: Management of Mental Health in Orthopaedic Patients

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Mental health evaluation should be considered an essential part of the routine preoperative assessment and should be managed by a multidisciplinary team composed of the primary care physician, orthopaedic provider, and behavioral health specialist.

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The scientific literature indicates that patients without comorbid psychiatric symptoms and adaptive coping strategies, resilience, and well-managed expectations have improved functional outcomes and satisfaction after orthopaedic procedures.

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Psychological issues are multifaceted and require treatment tailored to each individual patient. Therefore, close communication between all members of the care team is required to create and execute the perioperative plan.

Higher Dissatisfaction Rate Following Revision Compared With Primary Total Knee Arthroplasty: 1-Year Follow-up of 2151 Primary and 235 Aseptic Revision Surgeries

Postoperative patient satisfaction is related to preoperative expectations. Information regarding expected results following surgery is therefore important. This study evaluated patient-reported outcome measures (PROMs) and patient satisfaction up to 1 year after primary and aseptic revision total knee arthroplasty (TKA). The study included 2151 primary and 235 aseptic revision TKA surgeries conducted between 2010 and 2018. Pain, Knee Injury and Osteoarthritis Outcome Score-Physical Function-Short Form and European Quality of Life-5 Dimension surveys were recorded preoperatively and at 8 weeks and 1 year. To determine satisfaction, patients were asked to rate their knee function compared with that before surgery and to answer whether they would undergo the surgery again given their current knowledge. Patients who had primary TKA improved in all PROMs in each follow-up up to 1 year, whereas patients who had revision TKA showed improvement at 8 weeks with no further improvement at 1 year. In terms of patient satisfaction, 88% of patients in the primary TKA group reported better knee function, and 87% were willing to have the surgery again at 1 year; the proportions were lower for patients who underwent revision TKA (66% and 68%, respectively). Aseptic revision TKA demonstrates inferior PROMs compared with those of primary TKA 1 year after surgery, and more than 30% of the patients who underwent revision TKA stated that they would not have their TKA revised or were uncertain, given the outcome of the procedure. Thus, patients who are candidates for revision TKA should be informed to expect less of an improvement following revision surgery than with the primary TKA. Our findings can facilitate the shared decision-making process by surgeons and patients based on realistic expectations of surgical outcomes. [Orthopedics. 2023;46(1):e52-e57.].

The INDICATE Knee expectations survey detects general patient treatment goals for total knee arthroplasty and the influence of demographic factors on patients expectations

PURPOSE

Post-operative outcome after total knee arthroplasty (TKA) in the treatment of end-stage osteoarthritis correlates strongly with pre-operative impairment-driven patient treatment goals. However, a clinical tool for measuring patient treatment goals in correlation to impairments is still missing, which impedes patient-oriented indication in TKA.

METHODS

Patients scheduled for TKA were recruited in four German hospitals. All patients were handed the INDICATE Knee Score pre-operatively. The score contains 31 treatment goals with respective impairments, subdivided into seven categories. They were asked to rank all treatment goals and impairments on a 3-point scale. Treatment goals and impairments were then checked for frequency of occurrence. Correlation of goal and impairment was tested. Analysis for associations of treatment goals and different cohort characteristics (age, sex, BMI) was conducted.

RESULTS

1.298 patients were included in the study. Seven treatment goals were categorised as "main goal" from more than 90% of all patients ("knee pain", "range of motion", "walking distance", "overall physical function", "climbing stairs", "quality of life", "implant survival"). Comparing age groups, there were significant associations towards higher expectations regarding working, physical and sports related treatment goals in younger patients (< 65y) ("ability to work" (P ≤ .001), "sports activities" (P ≤ .001), "sex life" (P ≤ .001), "dependence on help of others" (P = .015), "preventing secondary impairment" (P = .03), "dependence on walking aids" (P = .005)). Higher BMI resulted in increasing relevance of "weight reduction" (P ≤ .001), "climbing stairs" (P = .039) "global health status" (P = .015) and "long standing" (P = .007) as a "main goal". Analysis for differences in treatment goals regarding sex showed women choosing more treatment goals as "main goals" than men.

CONCLUSION

Seven treatment goals which were expected by > 90% in our collective can be classified as general treatment goals for TKA. Demographic factors (age, sex, BMI) were significantly associated with patients' expectations for TKA. We conclude physicians should clearly assess their patients' demands prior to TKA to maximise post-operative outcome.

LEVEL OF EVIDENCE

Prognostic Level III.

Higher preoperative expectations predict better outcomes in shoulder surgery patients

PURPOSE

The purpose of this study is to determine if preoperative expectations (PE) are an independent predictor of greater 2-year outcomes and greater improvement from baseline in shoulder surgery patients.

METHODS

Two-hundred and sixteen patients who underwent shoulder surgery at one institution were studied. Patients completed both preoperative and 2-year follow-up questionnaires including PROMIS (Patient-Reported Outcome Measurement Information System) computer-adaptive testing in six domains, American Shoulder and Elbow Surgeons (ASES) score, shoulder numeric pain scale (NPS), and the Marx Shoulder Activity Rating Scale (MARS). PE were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) expectations domain, and satisfaction was measured via the Surgical Satisfaction Questionnaire (SSQ-8).

RESULTS

The mean PE score was 86.2 ± 17.8. Greater PE were associated with significantly better 2-year scores for ASES, NPS, MARS, SSQ8, and PROMIS domains of Physical Function, Fatigue, Pain Interference Fatigue and Social Satisfaction. Multivariable analyses demonstrated that greater PE were an independent predictor of both better 2-year scores and greater improvement for PROMIS SS (p < 0.001), ASES (p = 0.007), and shoulder NPS (p = 0.011).

CONCLUSION

Greater PE are positively associated with numerous patient-based outcomes 2 years after surgery. With regards to pain relief, shoulder function, and social satisfaction, higher PE are also predictive of better outcome scores and more improvement. This study suggests that preoperative assessment of shoulder surgery PE is important, and that counseling patients to optimize realistic expectations may lead to superior outcomes.

LEVEL OF EVIDENCE

III.

Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS

Background

Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms.

Methods

From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used.

Results

A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores.

Conclusion

Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms.

Level of Evidence

Level III, case-control study.

Patient expectations and satisfaction in hand surgery: A new assessment approach through a valid and reliable survey questionnaire

INTRODUCTION

Assessing patient expectations in orthopaedic surgery has gained significant importance over time. However, there have been only a few studies on how to measure such expectations in hand surgery. Against the backdrop, the study was designed to develop a valid and reliable expectations survey for patients undergoing hand surgery and to identify the correlations between preoperative expectations and postoperative satisfaction.

MATERIALS AND METHODS

This is a three-phase prospective cohort study. In the first phase of the study (146 patients), patient expectations were assessed while developing a draft questionnaire based on frequency and clinical relevance. In the second phase (154 patients newly included), test-retest reliability was measured to ensure test consistency. The Intraclass Correlation Coefficient (ICC) served as a basis for developing the final survey questionnaire. In the third phase, we followed up with patients, who completed the preoperative expectations survey, 3 months after surgery to assess the fulfillment of their expectations. The Pearson correlation method was used to measure the association between preoperative expectations and postoperative satisfaction.

RESULTS

In the first phase, 146 patients shared 406 different expectations, which were grouped into nine categories. Then, in the second phase, the final survey was populated by questionnaire items under respective category that have revealed strong test-retest reliability (ICC of 0.91). A significant positive correlation between patient expectations and satisfaction was observed (R = 0.181, p = 0.034).

CONCLUSION

The survey was designed to offer a valid and reliable approach for the comprehensive assessment of patient expectations in hand surgery. The survey results show that patients with high expectations tend to be more satisfied with surgical outcomes. It is strongly believed that this approach would serve as a useful tool at a time when patient perspective is taken into account increasingly more in the clinical practice.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles

BACKGROUND

In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time.

PATIENTS AND MATERIALS

A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed.

RESULTS

A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008.

CONCLUSION

Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

PATIENT SATISFACTION WITH INTERPERSONAL COOPERATION AND HEALTH SERVICES AT THE LEVEL OF PRIMARY AND SECONDARY HEALTH CARE

Interprofessional cooperation and teamwork among health professionals in the health care system are crucial for improving patient satisfaction and quality of health services. The aim of the research is to examine the satisfaction of patients with interpersonal cooperation and health services provided at the level of primary and secondary health care. The research was done as a cross-sectional study and was conducted at the Niksic General Hospital and two health centers in Podgorica. The sample consisted of 154 respondents, both sexes. The research used a questionnaire for health care users designed for the purposes of this research. The questionnaire consists of a general and a specific part. Descriptive statistics measures and x2 test were used for statistical data processing. The results of the research show that there is a statistically significant correlation between gender and patient satisfaction with services χ² (2, N = 154) = 104.117, p = 0.000, as well as between age and patient satisfaction with services χ² (6, N = 154) = 139.294, p = 0.000. Understanding interpersonal cooperation is important for improving the efficiency of health care, its organization and customer satisfaction.

Depression and anxiety are associated with worse baseline function in hip arthroscopy patients

PURPOSE

The purpose of this study was to analyze the correlation between baseline depression and anxiety and preoperative functional status in hip arthroscopy patients.

METHODS

A prospective, institutional review board-approved orthopaedic registry was used to retrospectively study 104 patients undergoing hip arthroscopy. Enrolled patients were administered baseline questionnaires for Patient-Reported Outcomes Measurement Information System (PROMIS) domains, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) preoperative expectations, and Numeric Pain Scale (NPS).

RESULTS

The average baseline PROMIS Depression and Anxiety scores were 49.9 ± 9.8 and 55.5 ± 9.3, respectively. Bivariate analysis demonstrated that greater baseline PROMIS Anxiety correlated with worse preoperative PROMIS PI (p < 0.001), Fatigue (p < 0.001), Social Satisfaction (p < 0.001), and NPS score (p = 0.013). Bivariate analysis showed that greater PROMIS Depression correlated with worse preoperative PROMIS PF (p = 0.001), PI (p < 0.001), Fatigue (p < 0.001), SS (p < 0.001), and NPS score (p = 0.004). After controlling for confounders, multivariable analysis confirmed increased PROMIS Depression as an independent predictor of worse preoperative PROMIS PF (p = 0.009), MODEMS Expectations (p = 0.025), and NPS score (p = 0.002). Increased PROMIS Anxiety was predictive of worse baseline PROMIS PI (p < 0.001), Fatigue (p < 0.001), and Social Satisfaction (p < 0.001). A previous clinical diagnosis of depression or anxiety was only an independent predictor of worse baseline PROMIS Fatigue (p = 0.002) and was insignificant in all other models.

CONCLUSION

Increasing severity of depression and anxiety correlated with and predicted worse functional status at baseline in hip arthroscopy patients. As compared to clinical diagnosis of anxiety and depression, PROMIS metrics have superior utility in recognizing potentially modifiable mental health concerns that predict worse preoperative status. Ultimately, the study identifies an at-risk population undergoing hip arthroscopy that requires particular attention and potential mental health intervention in the preoperative setting.

LEVEL OF EVIDENCE

III.

Side-to-side differences in postoperative function and patient satisfaction after bilateral total shoulder arthroplasties

BACKGROUND

As the number of anatomic and reverse total shoulder arthroplasty (TSA) procedures increase, there will be a natural increase in patients who undergo staged bilateral TSA procedures. Bilateral TSAs have been shown to improve patient outcomes; however, it is unknown whether these patients experience side-to-side differences in clinical outcomes and satisfaction between shoulders. Understanding these differences is imperative for accurate patient and provider expectations.

METHODS

An international multicenter registry was used to identify patients who underwent staged bilateral TSAs from April 2007 to October 2019 with a minimum of 2-year follow-up. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) outcomes and satisfaction ratings were compared between dominant and nondominant shoulders, and first and second arthroplasties. Side-to-side differences in postoperative ASES and unequal satisfaction ratings were also explored by using regression analyses to identify potential factors influencing these differences.

RESULTS

A total of 60 patients (22 bilateral anatomic TSAs, 38 bilateral reverse TSAs) were identified for inclusion. Group analyses revealed that bilateral TSA patients demonstrated similar functional outcomes and satisfaction regardless of dominance and surgery sequence. Type of TSA, specifically bilateral reverse TSAs, significantly predicted greater side-to-side differences in postoperative ASES scores (P = .025), indicating reverse TSA patients demonstrated greater between-sides differences in postoperative functional outcomes compared with those undergoing anatomic TSAs. Additionally, a larger proportion of bilateral reverse TSA patients reported unequal satisfaction between shoulders (31.6%) compared with anatomic TSA patients (9.1%). Logistic regression analysis revealed that greater side-to-side differences in postoperative ASES scores were found to increase the likelihood of reporting unequal satisfaction between shoulders (odds ratio 1.11, P < .001), which may explain this outcome.

CONCLUSIONS

Most patients who undergo bilateral TSAs can expect similar outcomes on both shoulders regardless of dominance and surgery sequence. However, we did find patients who had discordant results between shoulders. Those who underwent reverse TSAs more frequently reported unequal satisfaction with their TSA procedures, which is likely due to larger side-to-side differences in postoperative function. It is unclear why these differences occurred, but this information may be important for providers to remember when counseling these patients for accurate postoperative expectations.

Public Perceptions of Opioid Use Following Orthopedic Surgery: A Survey

Background: The United States accounts for the majority of prescription opioids consumed worldwide. Recent literature has focused on opioid prescribing patterns among orthopedic surgeons; however, public and patient expectations about postoperative opioid use remain understudied. Purpose: We sought to explore public perceptions of opioid use after elective orthopedic surgery. Methods: We posted a 32-question survey on Amazon Mechanical Turk (MTurk), an online platform with over 500,000 unique registered users that is a validated tool for collecting survey responses in medical research. The survey asked about attitudes regarding opioid use after elective orthopedic surgery and sociodemographic factors, as well as validated assessments of health literacy and patient engagement. Results: Of 727 respondents who completed surveys, nearly half (46%) said they would prefer nonopioid pain medication after elective orthopedic surgery, although 86% said they would expect to be prescribed opioids for 1 week to 1 month postoperatively. About half said they would expect to be prescribed extra opioid medication in case of unexpected pain following surgery, and 50% reported that they would save their pills to treat future pain. Approximately 63% said they would understand their surgeon's opioid weaning, but over ⅓ said weaning would lead to decreased satisfaction with their surgeon. Roughly ⅔ reported that pain control after surgery would directly affect their opinion of the surgeon. Conclusions: Our survey found that some members of the general public reported expectations regarding postoperative opioid prescribing that could lead to decreased patient satisfaction. These findings suggest the need for further research on the value of preoperative patient education in pain management, on patient expectations of pain control after elective surgery, and on the use of opioids following orthopedic surgery.

Reliability and Validity of Adapted Russian Version of Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey

Background: Patients' expectations are an important determinant in their decision to undergo lumbar spinal surgery-particularly their expectations of recovery after surgery. The Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey (HSS-LSSES) is one tool used to assess this; however, the original version was only available in English. Objective: We sought to evaluate the reliability and validity of a translated and adapted Russian-language version of the HSS-LSSES. Methods: This was a prospective study of 91 patients with degenerative disc disease who underwent lumbar spine surgery with instrumented fixation at a single institution in Saint Petersburg, Russia. Patients were recruited between December 2019 and February 2021 and asked about their expectations of surgery with a translated and adapted Russian version of the HSS-LSSES. To analyze construct validity, participants also completed disease-specific and general quality-of-life scales (Oswestry Disability Index, European Quality of Life-5 Dimensions, and 36-item Short-Form Health Survey). Intraclass correlation coefficients (ICCs; 2-way random effects model, absolute agreement) were used to determine test-retest reliability of the total score of the Russian HSS-LSSES. Internal consistency was evaluated through the estimation of Cronbach's alpha between the test and retest response of the questionnaire. Results: The test-retest stability of the Russian HSS-LSSES evaluated through the estimation of ICC was found to have good stability. The instrument was shown to have high internal consistency. Conclusion: This study demonstrates that a translated and adapted Russian version of HSS-LSSES had good internal consistency, reliability, construct validity, and no floor and ceiling effects. Therefore, we recommend its use as a tool for evaluating Russian-speaking patients' expectations before lumbar spine surgery.

Patient-Specific E-mailed Discharge Instructions Improve Patient Satisfaction and Patient Understanding After Surgical Arthroscopy

Purpose

The purpose of this study is to determine whether patient-specific e-mails after surgical arthroscopy improve patient satisfaction and patient understanding of their procedure compared to traditional, preprinted discharge instructions.

Methods

Sixty patients who underwent surgical arthroscopy were prospectively, randomized into two separate groups. One cohort received a detailed e-mail of their procedure, discharge instructions, and labeled intraoperative arthroscopic images, while the second cohort received the standard preprinted instructions, while their arthroscopic images were discussed at the time of follow-up. The procedures were performed by a single surgeon. All patients were seen at 1-week follow-up and given a 14-question survey specific to their postoperative course, discharge instructions, and overall satisfaction using a 5-point Likert Scale. Demographic information was collected and data points comparing overall patient satisfaction, ease of understanding instructions, quality of information, and the number of times referenced were analyzed using nonparametric tests between the two cohorts.

Results

Patients in the e-mail cohort were significantly more satisfied with their surgery than patients in the printed cohort (medians: 5 versus 4, Wilcoxon chi-square = 9.98; P =.002). Patients in the e-mail cohort indicated that their instructions more greatly enhanced their overall understanding of their surgery (medians: 5 vs 3, Wilcoxon chi-square = 10.84; P = .001) and were more helpful to their recovery (medians: 5 vs 3, Wilcoxon chi-square = 7.37; P = .007). E-mail patients were significantly more likely to recommend similar instructions be sent to a friend undergoing surgery (medians: 5 versus 3, Wilcoxon chi-square = 11.10; P < .001) and share their instructions with others 72% (18/25) versus 34.5% (10/29). There was no significant difference between the e-mail cohort and the print cohort for the number of times patients referred to their instructions (medians: 3 versus 3, Wilcoxon chi-square = 2.41; P =.121).

Conclusions

Patient-specific e-mailed discharge instructions improve patient satisfaction and overall understanding of the procedure compared with traditional printed discharge instructions after surgical arthroscopy.

Level of Evidence

Level II, prospective randomized trial.

The Impact of Effective Communication on Perceptions of Patient Safety—A Prospective Study in Selected Polish Hospitals

Interpersonal communication plays a key role in the treatment process. It affects not only the patient’s satisfaction with the course of treatment, but also allows the achievement of the best outcome in the therapeutic process. The process of patient empowerment and putting them in the role of a partner in the therapeutic process makes it possible to build a relationship based on trust, kindness and empathy. The aim of the study is to show the relationship between a patient’s sense of safety and access to health information, friendly and empathetic treatment by medical staff and a relationship based on trust. The study is conducted on patients from public hospitals in Wrocław by using the author’s questionnaire. One of the five most important factors according to respondents is the sense of safety, as reported by more than half of the patients (54.4%)—this is the opinion of more than half of the patients (54.4%). The respondents assessed the quality of patient care as an average of M = 41.1/50 points. There is a strong positive correlation between the sense of security and the access to information (rho = 0.642), kind treatment (rho = 0.623), trust in medical staff (rho = 0.758) and satisfaction with hospital stay (rho = 0.758).

Outcomes as experienced by older patients after hospitalisation: satisfaction, acceptance, frustration and hope-a grounded theory study

Background

outcomes of hospitalisation are often described in quantitative terms. It is unknown how older frail patients describe their own outcomes.

Objective

to discover how older frail persons describe their own hospitalisation outcomes and the meaning of these outcomes for their daily lives.

Design

Constructivist Grounded Theory approach.

Participants

frail older people discharged from hospital.

Methods

Open interviews in the participant’s home. Transcripts were coded inductively according to the Constructivist Grounded Theory approach.

Results

Twenty-four interviews were conducted involving 20 unique participants. Although for some participants hospitalisation was just a ripple, for others, it was a turning point. It could have positive or negative impacts on outcomes, including remaining alive, disease, fatigue/condition, complaints, daily functioning, social activities and intimate relationships, hobbies, living situation and mental well-being. Few participants were completely satisfied, but for many, a discrepancy between expectation and reality existed. Some participants could accept this, others remained hopeful and some were frustrated. Factors associated with these categories were research and treatment options, (un)clarity about the situation, setting the bar too high or pushing boundaries, confidence in physicians, character traits and social factors.

Conclusions

of the persons whose outcomes did not meet their expectations, some were frustrated, others hopeful and others accepted the situation. The following interventions can help patients to accept: clear communication about options and expectations before, during and after hospitalisation; giving room for emotions; help finding social support, encouragement to engage in pleasant activities and find meaning in small things. For some patients, psychological treatment may be needed.

Which Factors Are Associated With Satisfaction With Treatment Results in Patients With Hand and Wrist Conditions? A Large Cohort Analysis

BACKGROUND

Satisfaction with treatment results is an important outcome domain in striving for patient-centered and value-based healthcare. Although numerous studies have investigated factors associated with satisfaction with treatment results, most studies used relatively small samples. Additionally, many studies have only investigated univariable associations instead of multivariable associations; to our knowledge, none have investigated the independent association of baseline sociodemographics, quality of life, improvement in pain and function, experiences with healthcare delivery, and baseline measures of mental health with satisfaction with treatment results.

QUESTIONS/PURPOSES

(1) What factors are independently associated with satisfaction with treatment results at 3 months post-treatment in patients treated for common hand and wrist conditions? (2) What factors are independently associated with the willingness to undergo the treatment again at 3 months post-treatment in patients treated for common hand and wrist conditions? Among the factors under study were baseline sociodemographics, quality of life, improvement in pain and function, experiences with healthcare delivery, and baseline measures of mental health.

METHODS

Between August 2018 and May 2020, we included patients who underwent carpal tunnel release, nonsurgical or surgical treatment for thumb-base osteoarthritis, trigger finger release, limited fasciectomy for Dupuytren contracture, or nonsurgical treatment for midcarpal laxity in one of the 28 centers of Xpert Clinics in the Netherlands. We screened 5859 patients with complete sociodemographics and data at baseline. Thirty-eight percent (2248 of 5859) of these patients had complete data at 3 months. Finally, participants were eligible for inclusion if they provided a relevant answer to the three patient-reported experience measure (PREM) items. A total of 424 patients did not do this because they answered "I don't know" or "not applicable" to a PREM item, leaving 31% (1824 of 5859) for inclusion in the final sample. A validated Satisfaction with Treatment Result Questionnaire was administered at 3 months, which identified the patients' level of satisfaction with treatment results so far on a 5-point Likert scale (research question 1, with answers of poor, moderate, fair, good, or excellent) and the patients' willingness to undergo the treatment again under similar circumstances (research question 2, with answers of yes or no). A hierarchical logistic regression model was used to identify whether baseline sociodemographics, quality of life, change in outcome (patient-reported outcome measures for hand function and pain), baseline measures of mental health (including treatment credibility [the extent to which a patient attributes credibility to a treatment] and expectations, illness perception, pain catastrophizing, anxiety, and depression), and PREMs were associated with each question of the Satisfaction with Treatment Result Questionnaire at 3 months post-treatment. We dichotomized responses to our first question as good and excellent, which were considered more satisfied, and poor, moderate, and fair, which were considered less satisfied. After dichotomization, 57% (1042 of 1824) of patients were classified as more satisfied with the treatment results.

RESULTS

The following variables were independently associated with satisfaction with treatment results, with an area under the curve of 0.82 (95% confidence interval 0.80 to 0.84) (arranged from the largest to the smallest standardized odds ratio [SOR]): greater decrease in pain during physical load (standardized odds ratio 2.52 [95% CI 2.18 to 2.92]; p < 0.001), patient's positive experience with the explanation of the pros and cons of the treatment (determined with the question: "Have you been explained the pros and cons of the treatment or surgery?") (SOR 1.83 [95% CI 1.41 to 2.38]; p < 0.001), greater improvement in hand function (SOR 1.76 [95% CI 1.54 to 2.01]; p < 0.001), patients' positive experience with the advice for at-home care (determined with the question: "Were you advised by the healthcare providers on how to deal with your illness or complaints in your home situation?") (SOR 1.57 [95% CI 1.21 to 2.04]; p < 0.001), patient's better personal control (determined with the question: "How much control do you feel you have over your illness?") (SOR 1.24 [95% CI 1.1 to 1.40]; p < 0.001), patient's more positive treatment expectations (SOR 1.23 [95% CI 1.04 to 1.46]; p = 0.02), longer expected illness duration by the patient (SOR 1.20 [95% CI 1.04 to 1.37]; p = 0.01), a smaller number of symptoms the patient saw as part of the illness (SOR 0.84 [95% CI 0.72 to 0.97]; p = 0.02), and less concern about the illness the patient experiences (SOR 0.84 [95% CI 0.72 to 0.99]; p = 0.04). For willingness to undergo the treatment again, the following variables were independently associated with an AUC of 0.81 (95% CI 0.78 to 0.83) (arranged from the largest to the smallest standardized OR): patient's positive experience with the information about the pros and cons (determined with the question: "Have you been explained the pros and cons of the treatment or surgery?") (SOR 2.05 [95% CI 1.50 to 2.80]; p < 0.001), greater improvement in hand function (SOR 1.80 [95% CI 1.54 to 2.11]; p < 0.001), greater decrease in pain during physical load (SOR 1.74 [95% CI 1.48 to 2.07]; p < 0.001), patient's positive experience with the advice for at home (determined with the question: "Were you advised by the healthcare providers on how to deal with your illness or complaints in your home situation?") (SOR 1.52 [95% CI 1.11 to 2.07]; p = 0.01), patient's positive experience with shared decision-making (determined with the question: "Did you decide together with the care providers which care or treatment you will receive?") (SOR 1.45 [95% CI 1.06 to 1.99]; p = 0.02), higher credibility the patient attributes to the treatment (SOR 1.44 [95% CI 1.20 to 1.73]; p < 0.001), longer symptom duration (SOR 1.27 [95% CI 1.09 to 1.52]; p < 0.01), and patient's better understanding of the condition (SOR 1.17 [95% CI 1.01 to 1.34]; p = 0.03).

CONCLUSION

Our findings suggest that to directly improve satisfaction with treatment results, clinicians might seek to: (1) improve the patient's experience with healthcare delivery, (2) try to influence illness perception, and (3) boost treatment expectations and credibility. Future research should confirm whether these suggestions are valid and perhaps also investigate whether satisfaction with treatment results can be predicted (instead of explained, as was done in this study). Such prediction models, as well as other decision support tools that investigate patient-specific needs, may influence experience with healthcare delivery, expectations, or illness perceptions, which in turn may improve satisfaction with treatment results.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Fulfillment of Patient Expectations After Spine Surgery is Critical to Patient Satisfaction: A Cohort Study of Spine Surgery Patients

BACKGROUND

Patient satisfaction is an important indicator used to monitor quality of care and outcomes after spine surgery.

OBJECTIVE

To examine the complex relationship between preoperative expectations, fulfillment of expectations, postsurgical outcomes, and satisfaction after spine surgery.

METHODS

In this national study of patients undergoing elective surgery for degenerative spinal conditions from the Canadian Spine Outcomes and Research Network Registry, we used logistic regression to examine the relationships between patient satisfaction with surgery (1-5 scale), preoperative expectation score (0 = none to 100 = highest), fulfillment of expectations, and disability and pain improvement.

RESULTS

Fifty-eight percent of patients were extremely satisfied, and 3% were extremely dissatisfied. Expectations were variable and generally high (mean 79.5 of 100) while 17.3% reported that none of their expectations were met, 49.8% reported that their most important expectation was met, and 32.9% reported that their most important expectation was not met but others were. The results from the fully adjusted ordinal logistic model for satisfaction indicate that satisfaction was higher among patients with higher preoperative expectations (odds ratio [OR] [95% CI]: 1.11, [1.04-1.19]), reporting important improvements in disability (OR [95% CI]: 2.52 [1.96-3.25]) and pain (OR [95% CI]: 1.64 [1.25-2.15]) and reporting that expectations were fulfilled (OR = 80.15, for all expectations were met). The results were similar for lumbar and cervical patients.

CONCLUSION

Given the dominant impact of expectation fulfillment on satisfaction level, there is an opportunity for improving overall patient satisfaction by specifically assessing and mitigating the potential discrepancies between patients' preoperative expectations and likely surgical outcomes. The findings are likely relevant across elective surgical populations.

Patient Perceptions of Wearable and Smartphone Technologies for Remote Outcome Monitoring in Patients Who Have Hip Osteoarthritis or Arthroplasties

BACKGROUND

Although there is interest in wearables and smartphone technologies for remote outcome monitoring, little is known regarding the willingness of hip osteoarthritis (OA) and/or total hip arthroplasty (THA) patients to authorize and adhere to such treatment.

METHODS

We developed an Institutional Review Board-approved questionnaire to evaluate patient perceptions of remote monitoring technologies in a high-volume orthopedic center. Forty-seven THA patients (60% female; mean age: 66 years) and 50 nonoperative OA hip patients (52% female; mean age: 63 years) participated. Patient perceptions were compared using Pearson's chi-squared analyses.

RESULTS

THA patients were similarly interested in the use of smartphone apps (91% vs 94%, P = .695) in comparison to nonoperative hip OA patients. THA patients were more receptive to using wearable sensors (94% vs 44%, P < .001) relative to their nonoperative counterparts. THA patients also expressed stronger interest in learning to use custom wearables (87% vs 32%, P < .001) vs nonoperative patients. Likewise, the majority of THA patients were willing to use Global Positioning System technology (74% vs 26%, P < .001). THA patients also expressed willingness to have their body movement (89%), balance (89%), sleep (87%), and cardiac output (91%) tracked using remote technology.

CONCLUSION

Overall, we found that THA patients were highly receptive to using wearable technology in their treatments. Nonoperative OA hip patients were generally unreceptive to using smart technologies, with the exception of smartphone applications. This information may be useful as utilization of these technologies for patient care continues to evolve.

Editorial Commentary: Assessing Outcomes in Terms of Fulfillment of Patient Expectations Is Complementary to Traditional Measures Including Satisfaction

The topic of patients' expectations is receiving increasing attention as a patient-centered variable in preoperative orthopaedic assessment. Formally querying patients about expectations is necessary because surgeons may not be aware of these expectations, which often derive from multiple sources outside encounters with surgeons. Validated patient-derived surveys now exist for diverse orthopaedic surgeries to preoperatively measure expectations for improvement in symptoms and physical and psychological well-being. Assessing results of surgery in terms of fulfillment of these expectations is a patient-centered outcome that complements traditional measurements of satisfaction and pre- to postoperative change in symptoms and function. Validated follow-up surveys also now exist that ask patients for each item they expected before surgery, how much improvement have they actually received after surgery. The amount of improvement expected versus the amount of improvement received constitutes a measure of fulfilled expectations. The advantages of fulfillment of expectations as an outcome are that it prospectively includes both pre- and postoperative patients' perspectives and, because it is composed of multiple items, it can identify which symptoms and functions have improved to expected levels and which have not, thus providing the rationale for why patients rate outcomes the way they do. Therefore, measured in this way, postoperative fulfillment of expectations is a unique and novel patient-centered assessment for the comprehensive evaluation of orthopaedic surgical outcomes.