Health literacy and surgery expectations in total hip and knee arthroplasty patients

Readability, Understandability, Usability, and Cultural Sensitivity of Online Patient Educational Materials (PEMs) for Lower Extremity Reconstruction: A Cross-Sectional Study

Background: Lower extremity reconstructive surgery is an evolving field wherein patients rely on accessible online materials to engage with their perioperative care. This study furthers existing research in this area by evaluating the readability, understandability, actionability, and cultural sensitivity of online health materials for lower extremity reconstruction. Methods: We identified the 10 first-appearing, educational sites found by searching the phrases "leg saving surgery", "limb salvage surgery," and "leg reconstruction surgery". Readability analysis was conducted with validated tools, including Simple Measure of Gobbledygook (SMOG). Understandability and actionability were assessed with Patient Education and Materials Assessment Tool (PEMAT), while cultural sensitivity was measured with Cultural Sensitivity Assessment Tool (CSAT). A Cohen's κ value was calculated (PEMAT and CSAT analyses) for inter-rater agreement. Results: The mean SMOG reading level for websites was 13.12 (college-freshman reading level). The mean PEMAT understandability score was 61.8% and actionability score was 26.0% (κ = 0.8022), both below the 70% acceptability threshold. The mean CSAT score was 2.6 (κ = 0.73), exceeding the 2.5 threshold for cultural appropriateness. Conclusion: Online PEM for lower extremity reconstruction continue to fall below standards of readability, understandability, and actionability; however, they meet standards of cultural appropriateness. As patients rely on these materials, creators can use validated tools and positive examples from existing PEM for greater patient accessibility.

Treatment of Hip and Knee Periprosthetic Joint Infection Requires Extensive Administrative Work

BACKGROUND

Treatment of periprosthetic joint infections (PJIs) typically requires more resource utilization than primary total joint arthroplasty. This study quantifies the amount of time spent in the electronic medical record (EMR) for patients who have PJI requiring surgical intervention.

METHODS

A retrospective analysis of EMR activity for 165 hip and knee PJIs was performed to capture work during the preoperative and postoperative time periods. Independent sample t tests were conducted to compare total time based on procedure, age, insurance, health literacy, sex, race, and ethnicity.

RESULTS

The EMR work performed by the orthopaedic team was 338.4 minutes (min) (SD 130.3), with 119.4 minutes (SD 62.8) occurring preoperatively and 219.0 minutes (SD 112.9) postoperatively. Preoperatively, the surgeon's work accounted for 35.7 minutes (SD 25.4), mid-level providers 21.3 minutes (SD 15.9), nurses 38.6 minutes (SD 36.8), and office staff 32.7 minutes (SD 29.9). Infectious disease colleagues independently performed 158.9 minutes (SD 108.5) of postoperative work. Overall, PJI of the knees required more postoperative work. Secondary analysis revealed that patients who have hip PJI and a body mass index <30 and patients <65 years of age required more work when compared to the PJI of heavier and older individuals. There was no difference in total work based on insurance, health literacy, race, or ethnicity.

CONCLUSIONS

Over 8 hours of administrative work is required for surgical management of PJI. Surgeons alone performed 451% more work for PJI during the preoperative period (7.9 versus 35.7 min) compared to primary total joint arthroplasty. In efforts to provide best care for our sickest patients, much work is required perioperatively. This work is necessary to consider when assigning value and physician reimbursement.

Socioeconomic Factors Including Patient Income, Education Level, and Health Insurance Influence Postoperative Secondary Surgery and Hospitalization Rates Following Hip Arthroscopy

PURPOSE

To evaluate a large cross-sectional sample of patients utilizing administrative database records and analyze the effects of income, insurance type, and education level on outcomes after hip arthroscopy, including 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations.

METHODS

Current Procedural Terminology codes were used to query the PearlDiver Mariner database from October 2015 to January 2020 for patients undergoing hip arthroscopy with a minimum 2-year follow-up. Patients were categorized by mean family income in their zip code of residence (MFIR), health insurance type, and educational attainment in their zip code of residence (EAR). Two-year revision arthroscopy, conversion to THA, and 90-day hospital readmissions or emergency department (ED) visits were analyzed along socioeconomic strata.

RESULTS

Multivariate analysis of 33,326 patients revealed that patients with MFIR between $30,000 and $70,000 had lower odds of 2-year revision arthroscopy (odds ratio [OR], 0.63; P < .001), THA conversion (OR, 0.76; P = .050), and 90-day readmission (OR, 0.53; P = .007) compared to MFIR >$100,000. Compared to patients with commercial insurance, patients with Medicare had lower odds of revision arthroscopy (OR, 0.60; P = .035) and THA conversion (OR, 0.46, P < .001) but greater odds of 90-day readmission (OR, 1.74; P = .007). Patients with Medicaid had higher odds of 90-day ED visits (OR, 1.84; P < .001). Patients with low EAR had higher odds of revision arthroscopy (OR, 1.42; P = .005) and THA conversion (OR, 1.58; P = .002) compared to those with high EAR.

CONCLUSIONS

Following hip arthroscopy, patients residing in areas with lower mean family income were less likely to undergo reoperations and readmissions. Medicare patients showed lower reoperation but higher readmission odds, while Medicaid patients showed higher odds of ED visits. Additionally, higher educational attainment in the zip code of residence is protective against future reoperation.

LEVEL OF EVIDENCE

Level III, retrospective case series.

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Health literacy in orthopaedic lower limb trauma patients: A cross-sectional survey study

INTRODUCTION

The aim of this study was to investigate orthopaedic lower limb trauma patients' comprehension regarding the affected bone, the surgical implant used, and postoperative instructions, and to evaluate the relationship between sociodemographic features and health literacy.

HYPOTHESIS

There is a relationship between health literacy levels, the medical awareness of orthopaedic trauma patients and sociodemographic characteristics.

MATERIAL AND METHODS

The cross-sectional survey study was conducted from June to September 2021 in the orthopaedic clinic of a level 1 trauma centre. The study group consisted of 225 patients with a surgically treated unilateral lower limb fracture. The questionnaire consisted of 3 parts: (1) sociodemographic information, (2) knowledge about ongoing orthopaedic treatment, and (3) 16-item version of The European Health Literacy Survey (HLS-EU-Q16).

RESULTS

Of the patients in the study, 46% were not aware that they were using thromboembolism prophylaxis, and 10% did not use the prophylaxis. More than half of the patients did not know which bone was fractured, three-quarters did not know what type of implant had been used for the fracture fixation, and approximately 90% of the patients did not know their weight-bearing status and the expected healing time after surgery. Inadequacy of HLS-EU-Q16 score with a median of 34.4, (range, 0-50) was 38.7% (n=87).

DISCUSSION

Orthopaedic lower limb trauma patients demonstrated inadequate health literacy with low comprehension of their injuries, surgeries, and discharge schemes. This study's results show the need to promote more effective communication between orthopaedic trauma patients and healthcare providers. Identifying inadequate health literacy in patients and developing appropriate interventions before discharge may help improve outcomes.

LEVEL OF EVIDENCE

II; cross sectional.

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

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

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

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

Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees.

Methods

This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary.

Results

One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%).

Discussion

This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

The Effect of Education Planned According to Health Literacy Level on Functionality, Problems Experienced, and Quality of Life in Patients Undergoing Total Knee Replacement: A Nonrandomized Comparison Group Intervention Study

Total knee arthroplasty procedures significantly improve quality of life for persons with debilitating pain. It is essential to plan patient education according to the level of health literacy. This nonrandomized comparison group intervention study examines the effect of education planned according to health literacy level on functionality, postoperative problems (pain and anxiety), and quality of life in patients who undergo total knee replacement. During the study, patients in the intervention group (n = 51) were provided with the planned patient education according to their health literacy level, whereas patients in the comparison group were given routine care (n = 51). Patients in the postoperative intervention group experienced fewer problems (p < .05). Education tailored to patients' health literacy levels had a positive effect on their functionality and quality of life (p < .05). Our findings suggest planning education according to patient health literacy levels may have a positive influence on functionality, postoperative problems, and quality of life among patients undergoing total knee replacement.

Removing Pathoanatomical Content From Information Pamphlets About Knee Osteoarthritis Did Not Affect Beliefs About Imaging or Surgery, but Led to Lower Perceptions That Exercise Is Damaging and Better Osteoarthritis Knowledge: An Online Randomised Controlled Trial

OBJECTIVE: Compare the effects of osteoarthritis information, with or without pathoanatomical content, on people's beliefs about managing osteoarthritis. DESIGN: Online randomized controlled trial involving 556 participants. METHODS: Participants considered a hypothetical scenario where their doctor informed them that they had knee osteoarthritis. Participants were randomized to a control condition, where they received currently available osteoarthritis information with pathoanatomical content or an experimental condition, where they received the same osteoarthritis information but without pathoanatomical content. Primary outcomes were participants' beliefs about the need for x-ray to confirm diagnosis and joint replacement surgery in the future. RESULTS: There were no between-group differences in primary outcomes for x-ray (mean difference [MD], -0.3; 95% confidence interval [CI]: -0.9, 0.4) and surgery (MD, -0.2; 95% CI: -0.7, 0.2), each rated on an 11-point numeric rating scale. Participants in the experimental group had lower perceptions that exercise would damage the knee (MD, -0.4; 95% CI: -0.8, 0.0; rated on an 11-point numeric rating scale) and better osteoarthritis knowledge (MD, 0.9; 95% CI: 0.0, 1.9; rated on a scale ranging from 11 to 55). Among those without tertiary education, participants in the experimental group had lower perceptions that x-ray was necessary than control (MD, -0.8; 95% CI: -1.5, -0.1). Among those who had never sought care for knee pain, participants in the experimental group had lower perceptions about the need for surgery (MD, -0.7; 95% CI: -1.2, -0.2). CONCLUSIONS: Removing pathoanatomical content may not change beliefs about imaging and surgery but may lead to lower perceptions that exercise is damaging and may improve osteoarthritis knowledge. However, effects were small and of unclear clinical relevance. Tertiary education or a history of care seeking for knee pain may moderate effects on primary outcomes. J Orthop Sports Phys Ther 2023;53(4):1-15. Epub: 12 December 2022. doi:10.2519/jospt.2022.11618.

Hip and Knee Total Joint Arthroplasty Online Resources for Patients and Health Care Professionals: A Canadian Environmental Scan

Purpose:

To appraise the quality of publicly available online Canadian resources for patients with hip or knee osteoarthritis considering total joint arthroplasty (TJA) and health care professionals participating in TJA decision-making processes.

Method:

An environmental scan. Two independent authors appraised: a) patient resources against the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Material Evaluation Tool (PEMAT); and b) health care professional resources against six appropriateness criteria for TJA and eight elements of shared decision-making. Analysis was descriptive.

Results:

Of 84 included resources, 71 were for patients, 11 for health care professionals, and 2 for both. For patient resources, the median number of IPDAS defining criteria met was 2 of 7, median PEMAT understandability score was 83%, and median PEMAT actionability score was 60%. For health care professional resources, the median number of appropriateness criteria was 3 of 6, and the median number of shared decision-making elements was 3 of 8.

Conclusions:

Only four of 73 patient resources were structured to help patients consider their options and reach a decision based on their preferences. Health care professional resources were limited to traditional criteria for determining TJA appropriateness (evidence of osteoarthritis, use of conservative treatments) and poorly met key elements of shared decision-making.

Health Literacy in Orthopaedics

Health literacy is a dynamic, multifaceted skill set that relies on patients, healthcare providers, and the healthcare system. In addition, health literacy assessment provides an avenue for evaluating patient understanding and offers insights into their health management capabilities. Inadequate health literacy results in poor patient outcomes and compromised care by considerably hindering successful communication and comprehension of relevant health information between the patient and the provider. In this narrative review, we explore why limited health literacy poses serious implications for orthopaedic patient health and safety, expectations, treatment outcomes, and healthcare costs. Furthermore, we elaborate on the complexity of health literacy, provide an overview of key concepts, and offer recommendations for clinical practice and research investigations.

Evaluating first year residents' communication skills: a health literacy curriculum needs assessment

BACKGROUND

High quality communication skills are necessary for competent and ethical practice. When patients present with low health literacy, physicians' skills may be lacking, which can put patients' safety and satisfaction at risk. The authors' developed and executed a simulation-based needs assessment following conflicting internal reports about the communications skills of new residents.

METHODS

The current study recruited first year residents (N = 30) during the 2019 first post-graduate year (PGY-1) orientation at a southeastern university hospital simulation center. The residents completed an Objective Structured Clinical Examination (OSCE) which focused on obtaining informed consent from a patient's health care proxy who presented with limited literacy and health literacy and poor communication skills. After completing the OSCE, the residents, simulated patients (SP), and independent observers assessed the residents' performance.

RESULTS

Residents assessed their performance higher when compared with the ratings from independent observers and patient raters. Residents who spent more time with SPs were given higher ratings by the SPs and independent observers. Finally, residents' ratings of themselves had a positive correlation with their reported confidence, but no correlation between self-confidence and the ratings provided by SPs or observers.

CONCLUSION

PGY-1 residents demonstrate a continued need for health literacy and informed consent education, despite faculty believing that these skills were covered enough in medical school. These residents also demonstrated limited self-assessment ability or skills below the expectations of health literacy experts. Curriculum changes included improving the focus on health literacy, communication skills, and additional practice opportunities throughout their internship year.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparative effect of two educational videos on self-efficacy and kinesiophobia in people with knee osteoarthritis: an online randomised controlled trial

OBJECTIVE

To compare change in self-efficacy for managing knee osteoarthritis (OA) pain and kinesiophobia after watching an educational video based on an empowerment and participatory discourse with a video based on a disease and impairment discourse.

DESIGN

Two-arm randomised controlled trial with participants aged ≥45 years with knee pain (n = 589). Participants completed both baseline and follow-up outcomes and watched one randomly-allocated video (12-minute duration) during one 30-45-minute session within a single online survey. The experimental video presented evidence-based knee OA information using design and language that aimed to empower people and focus on activity participation to manage OA, while the control video presented similar information but with a disease and impairment focus. Primary outcome measures were Arthritis Self-Efficacy Scale pain subscale (range 0-10) and Brief Fear of Movement Scale for OA (range 6-24). Secondary outcomes were expectations about prognosis and physical activity benefits, perceived importance and motivation to be physically active, knee OA knowledge, hopefulness for the future, level of concern and perceived need for surgery.

RESULTS

Compared to control (n = 293), the experimental group (n = 296) showed improved self-efficacy for managing OA pain (mean difference 0.4 [95%CI 0.2, 0.6] units) and reduced kinesiophobia (1.6 [1.1, 2.0] units). The experimental group also demonstrated greater improvements in all secondary outcomes apart from hopefulness, which was high in both groups.

CONCLUSION

An educational video based on an empowerment and participatory discourse improved pain self-efficacy and reduced kinesiophobia in people with knee OA more than a video based on a disease and impairment discourse.

CLINICALTRIALS

gov registration NCT05156216, Universal trial number U1111-1269-6143.

Have all races experienced reductions in complication rates following total hip arthroplasty? A NSQIP analysis between 2011 and 2019

INTRODUCTION

Despite numerous articles in the orthopedic literature evaluating racial and ethnic disparities, inequalities in total joint arthroplasty outcomes remain. While the National Surgical Quality Improvement (NSQIP) database has been previously utilized to highlight these disparities, no previous analysis has evaluated how the rate of various perioperative complications has changed over recent years when segregating by patient race. Specifically, we evaluated if all races have experienced decreases in (1) medical complications, (2) wound complications, (3) venous thromboembolism (VTE), and (4) readmission/reoperation rates following total hip arthroplasty (THA) over recent years?

METHODS

Current Procedural Terminology (CPT) code 27,130 (total hip arthroplasty) was utilized to identify all THA procedures conducted between 2011 and 2019. Patients were segregated according to race and various demographics were collected. Linear regression was utilized to evaluate changes in each complication rate between 2011 and 2019. A multivariate regression was then conducted for each complication to evaluate whether race independently was associated with each outcome.

RESULTS

Our analysis included a total of 212,091 patients undergoing primary THA. This included 182,681 (85.76%) White, 19,267 (9.04%) Black, 5928 (2.78%) Hispanic, and 4215 (1.98%) Asian patients. We found that for urinary tract infection (UTI), acute renal failure, superficial SSI, and readmission rates, White patients experienced significant reductions between 2011 and 2019. However, this was not consistent across all races. Black race was associated with a significantly increased risk of acute renal failure (OR: 2.03, 95% CI: 1.17-3.34; p = 0.008), renal insufficiency (OR: 2.33, 95% CI: 1.62-3.28; p < 0.001), deep vein thrombosis (DVT) (OR: 1.34, 95% CI: 1.07-1.66; p = 0.01), and pulmonary embolism (PE) (OR: 1.76, 95% CIL: 1.36-2.24; p < 0.001).

CONCLUSION

Our analysis highlights specific complications for which further interventions are necessary to reduce inequalities across races. These include medical optimization, increased patient education, and continued efforts at understanding how social factors may impact-related care inequalities. Future study is needed to evaluate specific interventions that can be applied at the health systems level to ensure all patients undergoing THA receive the highest quality of care regardless of race.

The relationship between musculoskeletal health literacy and upper extremity patient-reported outcome measures (PROMs) in the setting of atraumatic shoulder pain

INTRODUCTION

Patient-reported outcome measures (PROMs) are commonly utilized to assess patient-derived orthopaedic health status and function. The prevalence of limited musculoskeletal health literacy (MHL) has been demonstrated to be high within the orthopaedic literature. The purpose of this study was to evaluate the association between MHL and upper extremity-specific PROMs and to determine which patient- and symptom-related factors affect baseline PROMs in patients with atraumatic shoulder pain.

HYPOTHESIS

Patients with limited MHL would demonstrate lower median scores on baseline PROMs compared with those with adequate MHL.

MATERIALS AND METHODS

New patients with atraumatic shoulder pain presenting to an academic practice were administered the Literacy in Musculoskeletal Problems (LiMP), in addition to the American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Single Assessment Numeric Evaluation (SANE) questionnaires. A detailed physical exam and history was performed by a fellowship-trained shoulder surgeon. Demographic patient data, in addition to prior imaging and orthopaedic treatment, was tabulated. The association between demographics, pain-related variables, and MHL with the ASES, SANE, and QuickDASH scores were examined using Spearman correlation coefficients for continuous variables and Wilcoxon rank-sum tests for categorical variables. Non-parametric analysis of covariance (ANCOVA) was used to examine the independent association of predictor variables with PROMs.

RESULTS

A total of 439 patients met the inclusion criteria and were enrolled. The mean age was 58.8±12.6years (range: 24-93) with 162 (37%) being men. Overall, 172 patients (39.2%) attained a college degree or higher and 183 (41.7%) were currently employed. MHL was significantly associated with ASES (p=0.03), but not with the QuickDASH (p=0.75) or SANE score (p=0.16). Similarly, age, having been in the medical profession or having previously visited an orthopaedist were not associated with PROMs, while employment status correlated to the SANE score (p=0.002). Visual Analogue Scale (VAS) pain level demonstrated varying strengths of association with each of the scores [ASES (r=-0.729, p<0.001), QuickDASH (r=0.557, p<0.001), and SANE (r=-0.430, p<0.001)]. MHL demonstrated no association with initial patient-derived treatment selection.

DISCUSSION

The SANE and QuickDASH may be administered to patients presenting for atraumatic shoulder pain in the outpatient setting regardless of MHL. Further research should be focused on the utility of the ASES instrument amongst patients with lower educational levels and/or limited MHL.

LEVEL OF EVIDENCE

II; diagnostic.

The role of digital health interventions to improve health literacy in surgical patients: a narrative review in arthroplasty

BACKGROUND

Arthroplasty is a high-volume but costly treatment option for advanced osteoarthritis. Health literacy and patient education are modifiable factors that can improve patient outcomes in arthroplasty. Digital technologies show potential as an instrument for providing patients with reliable information. This narrative review aimed to identify the current evidence for how effective digital health interventions (DHIs) are in targeting health literacy and related constructs (including knowledge, decision-making and self-efficacy) in arthroplasty.

METHODS

Six databases were searched for published studies comprising health literacy and related constructs, arthroplasty, and DHIs. The main outcome measure was health literacy. Two reviewer-authors independently screened studies according to predefined inclusion criteria and performed data extraction. Data was analysed and summarized in tabular and narrative form.

RESULTS

Two thousand seven-hundred and sixty-four titles and abstracts were screened. One hundred and sixty-seven papers underwent full-text analysis. No studies used health literacy as an outcome measure; therefore, the outcome measure was broadened to include its constructs, and the full-text analysis was repeated. Thirteen studies were included. No study following a structured design for their DHI. Eleven studies demonstrated participant improvement in constructs of health literacy, including knowledge, decision-making and self-management.

CONCLUSION

Current evidence suggests digital technology may provide new means of educating patients and improving aspects of their health literacy. More research digital technology with a structured approach, framework and standardized measures is required. Well-designed digital technology may become a useful adjunct to future patient care.

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

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

Extensive Preoperative Work Is Required for Revision Hip and Knee Arthroplasty

BACKGROUND

Determining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR).

METHODS

EMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05.

RESULTS

POW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy.

CONCLUSION

Revision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

Osteoarthritis management: Does the pharmacist play a role in bridging the gap between what patients actually know and what they ought to know? Insights from a national online survey

BACKGROUND

Guidelines encourage engagement in self-care activities for osteoarthritis (OA), but there are gaps in consumers' knowledge about suitable choices for self-care. Community pharmacists are in an ideal position to contribute to OA management through screening and supporting evidence-based pain management choices. Prior research established an association between health literacy and advice-seeking and appropriateness of analgesics choices (both lower in participants with limited health literacy) amongst people living with OA. This article explores the implications of these data for pharmacists in OA management.

METHODS

A national online survey was conducted amongst 628 adults aged 45-74 years, currently residing in Australia, with self-reported symptoms of OA. All data were collected using a customized online questionnaire, which was completed only once. 'Self-reported symptoms of OA' was based on six validated screening questions to identify people with OA without a formal clinical diagnosis.

RESULTS

Respondents matched the typical profile of people diagnosed with OA; more than half were female (56%), knees (59%) and hips (31%) were the primary affected joints and 74% were either overweight or obese. Self-identification of OA was limited (41%). Overall, 38% self-managed their pain, and limited health literacy was associated with less advice-seeking. Efficacy and ease of use were the main reasons cited for prompting use across all classes of nonprescription analgesic, with less than 20% reporting recommendation from a pharmacist. Participants were managing their pain with an average of 1.74 (95% confidence interval: 1.60-1.88) analgesics, but 73% reported inadequate pain relief and 54% had disrupted sleep.

CONCLUSION

Our findings highlight three key themes: lack of self-identification of OA, suboptimal pain relief and limited use of the community pharmacist as a source of management advice. Equipping community pharmacists with tools to identify OA could bridge this gap. More research is needed to determine if it will improve consumers' ability to appropriately manage OA pain.

PATIENT OR PUBLIC CONTRIBUTION

Consumers living with OA contributed to the study outcomes, reviewed the survey questionnaire for face validity and advised on plain language terminology.

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

BACKGROUND

The purpose of this study was to investigate if there is an association between musculoskeletal health literacy with outcome and satisfaction after total knee arthroplasty (TKA).

METHODS

A cross-sectional study was performed at our tertiary center to include patients between one and six years postoperatively after primary TKA. Patients were provided a survey including basic demographics, validated musculoskeletal health literacy scale (Literacy in Musculoskeletal Problems), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and TKA satisfaction (whether they would choose to undergo the same operation again). Patients were categorized as either low or normal health literacy based on number of questions (cutoff 6 out of 9) answered correctly on the Literacy in Musculoskeletal Problems. Statistical analysis included multivariate regression with significance at P < .05.

RESULTS

Four hundred fifty-three individuals fully completed the survey of eligible participants. Two hundred ninety-six individuals (65.3%) had normal health literacy, and one hundred fifty-seven individuals (34.7%) had low health literacy. Average WOMAC (/96) was 18.0 ± 19.7 in the low and 12.1 ± 15.4 in the normal health literacy groups. Patients with low health literacy had significantly higher WOMAC (worse function) than those with normal health literacy (P = .001). Patients with normal musculoskeletal health literacy were significantly more likely to undergo the same operation again (P = .01, odds ratio 2.163).

CONCLUSION

This study shows that patients with low musculoskeletal health literacy have worse outcome scores and are less likely to be satisfied with their TKA. By identifying these patients preoperatively, emphasis can be placed on enhancing procedure expectations and understanding to improve outcome measures and overall satisfaction.

Electronic Medical Record Audit Time Logs as a Measure of Preoperative Work Before Total Joint Arthroplasty

BACKGROUND

In order to achieve rapid recovery total joint arthroplasty, surgeons and their teams are spending more time in the weeks before surgery to prepare patients. This study aims to quantify total knee and hip prearthroplasty work using retrospective electronic medical record (EMR) activity audit log analysis.

METHODS

EMR activity in 100 elective knee and 100 elective hip arthroplasty cases was performed using audit logs. Each mouse click and action in the EMR was recorded. The time between mouse clicks was calculated and summed for each member of the clinical team. Descriptive statistics and independent samples t-tests were conducted to quantify and compare total preoperative work (POW) between groups defined by gender, procedure, age, insurance type, or health literacy (P < .05).

RESULTS

The mean number of days defined in the prearthroplasty time period was 69.1 days (standard deviation [SD] 42.8; range 8-191). The mean time spent in each patient's chart in the prearthroplasty period was 76.8 (SD 47.8) minutes. Surgeon's work in the medical record accounted for 7.9 (SD 7.9) minutes, registered nurses 46.7 minutes (SD 39.1), physician extenders 10.8 minutes (SD 16.9), and licensed practical nurses and patient care technicians 9.8 minutes (SD 13.0). A significant difference was observed when groups were dichotomized based on age <65 and insurance provider type.

CONCLUSION

A considerable amount of POW is required to prepare patients for surgery from the clinic date one decides to pursue total joint arthroplasty and the day prior to surgery. Retrospective electronic time stamps from the EMR should represent the minimum time required for surgical preparation.

How much improvement can satisfy patients? Exploring patients' satisfaction 3 years after total knee arthroplasty

Background

Despite the innovations in total knee arthroplasty (TKA), there is still a subset of patients who do not acquire significant relief or expected satisfaction after primary TKA. However, this subgroup of patients still gains improvements more or less in terms of objective or quantified assessments after the procedure. The purpose of our study is to explore the factors that correlate with patients’ satisfaction and identify minimal clinically important difference (MCID) and minimum important change (MIC) in clinical parameters.

Methods

We conducted a retrospective study of 161 patients diagnosed with osteoarthritis who underwent unilateral total knee arthroplasty from January 2017 to December 2017. We collected the following parameters: body mass index (BMI), duration of disease, education level, depression state, preoperative flexion contracture angle of knee, HSS scores, 11-point NRS scores, and radiological parameters (preoperative minimal joint space width and varus angle of knee). The satisfaction was graded by self-reported scores in percentage (0–100).

Results

We revealed that 80.8% of patients were satisfied 3 years overall after primary TKA. HSS score change, NRS-Walking score change, age, and pre-mJSW showed significant difference between satisfied and dissatisfied group. The varus angle change revealed statistical significance according to the levels of satisfaction. Simple linear regression identified the MCID for HSS score to be 5.41 and for the NRS-Walking to be 1.24. The receiver operating characteristics (ROC) curve identified the MIC for HSS score to be 25.5 and for the NRS-Walking score to be 6.5.

Conclusions

In summary, we identified several factors that correlated with patients’ satisfaction independently after TKA in a long term. In addition, we revealed the minimal clinically important difference (MCID) and minimum important change (MIC) for HSS and NRS score in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02514-2.

Does Health Literacy Make a Difference? Comparing the Effect of Conventional Medicine Versus Homeopathic Prescribing on Treatment Credibility and Expectancy

Objective

While homeopathic remedies are often used to treat non-specific complaints such as headaches, empirical evidence suggests their treatment effect is due to the placebo effect. Low health literacy seems to be connected to higher use of complementary and alternative medicine (CAM). The aim of this study was to examine what people with occasional headaches expect from conventional medicine or homeopathic remedies and if health literacy interacts with this expectation.

Methods

In this experimental study, n = 582 participants with occasional headaches were randomized to read one of two vignettes, which described the prescription of either conventional medicine or a homeopathic remedy. Subsequently, the participants were asked to rate treatment credibility and expectancy with regard to their assigned vignette. Health literacy was assessed as a potential moderator.

Results

Participants in the conventional medicine group rated treatment credibility and expectancy higher than in the homeopathic remedy group. Moderation analysis revealed that when being offered conventional medicine, participant reports of treatment credibility and expectancy decreased with lower health literacy, while these outcomes increased with lower health literacy for homeopathic remedies.

Discussion

People with occasional headaches estimate the effectiveness of conventional medication properly. However, health care professionals should pay special attention to patients with low health literacy, as they might need more time and information to give their informed consent.

Gamifying health literacy: how can digital technology optimize patient outcomes in surgery?

The digital age is entrenched in our society, with constant innovation driving change in the way clinicians and patients manage their health concerns. Health literacy is emerging as an important modifiable factor that can affect clinical and patient outcomes, yet traditional forms of patient education have shown mixed results. Digital media and technologies, the concept of gamification as a means to improve patient health literacy, and its potential for misuse will be explored in this review, in the context of a digital, gamified tool that could support patients along their surgical journey.

Association Between Baseline PROMIS Scores, Patient-Provider Communication Factors, and Musculoskeletal Health Literacy on Patient and Surgeon Expectations in Foot and Ankle Surgery

BACKGROUND

Various factors may affect differences between patient and surgeon expectations. This study aimed to assess associations between patient-reported physical and mental status, patient-surgeon communication, and musculoskeletal health literacy with differences in patient and surgeon expectations of foot and ankle surgery.

METHODS

Two hundred two patients scheduled to undergo foot or ankle surgery at an academic hospital were enrolled. Preoperatively, patients and surgeons completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed Patient-Reported Outcomes Measurement Information System (PROMIS) scores in Physical Function, Pain Interference, Pain Intensity, Depression, and Global Health. Patient-surgeon communication and musculoskeletal health literacy were assessed via the modified Patients' Perceived Involvement in Care Scale (PICS) and Literacy in Musculoskeletal Problems (LiMP) questionnaire, respectively.

RESULTS

Greater differences in patient and surgeon overall expectations scores were associated with worse scores in Physical Function (P = .003), Pain Interference (P = .001), Pain Intensity (P = .009), Global Physical Health (P < .001), and Depression (P = .009). A greater difference in the number of expectations between patients and surgeons was associated with all of the above (P ≤ .003) and with worse Global Mental Health (P = .003). Patient perceptions of higher surgeons' partnership building were associated with a greater number of patient than surgeon expectations (P = .017). There were no associations found between musculoskeletal health literacy and differences in expectations.

CONCLUSION

Worse baseline patient physical and mental status and higher patient perceptions of provider partnership building were associated with higher patient than surgeon expectations. It may be beneficial for surgeons to set more realistic expectations with patients who have greater disability and in those whom they have stronger partnerships with. Further studies are warranted to understand how modifications in patient and surgeon interactions and patient health literacy affect agreement in expectations of foot and ankle surgery.

LEVEL OF EVIDENCE

Level II, prospective comparative series.

Osteosarcoma Online Resources: A Quantitative Assessment of the Understandability and Readability of Web-based Patient Education Material (Preprint)

Background

Patients often turn to web-based resources following the diagnosis of osteosarcoma. To be fully understood by average American adults, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend web-based health information to be written at a 6th grade level or lower. Previous analyses of osteosarcoma resources have not measured whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT) is a validated measurement of understandability and actionability.

Objective

The purpose of this study was to evaluate web-based osteosarcoma resources using measures of readability, understandability, and actionability.

Methods

Using the search term “osteosarcoma,” two independent Google searches were performed on March 7, 2020 (by AGS), and March 11, 2020 (by TRG). The top 50 results were collected. Websites were included if they were directed at providing patient education on osteosarcoma. Readability was quantified using validated algorithms: Flesh-Kincaid Grade Ease (FKGE), Flesch-Kincaid Grade-Level (FKGL). A higher FKGE score indicates that the material is easier to read. All other readability scores represent the US school grade level. Two independent PEMAT assessments were performed with independent scores assigned for both understandability and actionability. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Statistical significance was defined as P≤.05.

Results

Two searches yielded 53 unique websites, of which 37 (70%) met the inclusion criteria. The mean FKGE and FKGL scores were 40.8 (SD 13.6) and 12.0 (SD 2.4), respectively. No website scored within the acceptable NIH or AHA recommended reading level. Only 4 (11%) and 1 (3%) website met the acceptable understandability and actionability threshold. Both understandability and actionability were positively correlated with FKGE (ρ=0.55, P<.001; ρ=0.60, P<.001), but were otherwise not significantly associated with other readability scores. There were no associations between readability (P=.15), understandability (P=.20), or actionability (P=.31) scores and Google rank.

Conclusions

Overall, web-based osteosarcoma patient educational materials scored poorly with respect to readability, understandability, and actionability. None of the web-based resources scored at the recommended reading level. Only 4 achieved the appropriate score to be considered understandable by the general public. Authors of patient resources should incorporate PEMAT and readability criteria to improve web-based resources to support patient understanding.

Health Literacy and Recall of Postoperative Instructions in Patients Undergoing the Lapidus Procedure

Background:

Active participation in patients’ own care is essential for success after Lapidus procedure. Poor health literacy, comprehension, and retention of patient instructions may be correlated with patient participation. Currently, there is no objective measure of how well patients internalize and retain instructions before and after a Lapidus procedure. We performed this study to assess how much of the information given to patients preoperatively was able to be recalled at the first postoperative visit.

Methods:

All patients between ages 18 and 88 years undergoing a Lapidus procedure for hallux valgus by the senior author between June 2016 and July 2018 were considered eligible for inclusion. Patients were excluded if they had a history of previous bunion surgery or if the procedure was part of a flatfoot reconstruction. Patients were given written and verbal instructions at the preoperative visit. Demographic and comprehension surveys were administered at their first visit approximately 2 weeks postoperatively. A total of 50 patients, of which 42 (84%) were female and 43 (86%) had a bachelor’s degree or higher, were enrolled.

Results:

Mean overall score on the comprehension survey was 6.2/8 (±1.2), mean procedure subscore was 1.8/3 (±0.64), and mean postoperative protocol subscore was 4.4/5 (±0.8). The most frequently missed question asked patients to identify the joint fused in the procedure.

Conclusion:

Although comprehension and retention of instructions given preoperatively was quite high in our well-educated cohort, our findings highlight the importance of delivering clear instructions preoperatively and reinforcing these instructions often.

Level of Evidence:

Level II, prospective cohort study.

Impact of gender and race on expectations and outcomes in total knee arthroplasty

BACKGROUND

Total joint arthroplasty is one of the most common surgeries performed in the United States with total knee arthroplasty (TKA) being one of the most successful surgeries for restoring function and diminishing pain. Even with the demonstrated success of TKA and a higher prevalence of arthritis and arthritis related disability among minorities, racial and gender disparity remains a constant issue in providing care for the adult reconstruction patient.

AIM

To assess the role of demographics and expectations on differences in perioperative patient reported outcomes (PRO) following TKA.

METHODS

One hundred and thirty-three patients scheduled for primary unilateral TKA secondary to moderate to severe osteoarthritis were enrolled in this two-institution prospective study. Validated PRO questionnaires were collected at four time points. Statistical analysis was conducted to determine the impact of gender, ethnic background and expectation surveys responses to assess PRO at these time points.

RESULTS

Females were associated with worse preoperative Knee Injury and Osteoarthritis Outcome Scores (KOOS) for symptoms, pain, and activities of daily living. African Americans were associated with worse KOOS for pain, activities of daily living, and quality of life. Despite worse preoperative scores, no difference was noted in these categories between the groups postoperatively. Additionally, all pre-operative psychometric scales were equivalent across groups except Geriatric Depression scale, which was significantly different between groups within the Race and Age Group (P < 0.05). Conversely, Pain Catastrophizing Scale, was significantly different for all subscales and total score within Age Group (P < 0.05), and the Magnification, Helplessness subscales as well as the Total score were significantly different between groups for Race and Relationship Status (P < 0.01).

CONCLUSION

We conclude that female and African American patients have lower preoperative KOOS scores compared to white male patients. No postoperative differences in outcomes between these groups.

Delving deeper into disparity: The impact of health literacy on the surgical care of breast cancer patients

BACKGROUND

Breast surgical oncology is a unique field that involves complex cancer management and longstanding patient interactions with the healthcare system, making it potentially challenging for patients with low health literacy. The purpose of this review is to summarize the current knowledge regarding health literacy in breast cancer and identify future directions for research and potential intervention in breast surgical oncology.

DATA SOURCES

A search of relevant literature querying PubMed and Science Direct was performed and included the following keywords: health literacy, breast cancer, breast surgical oncology, surgery, outcomes, prevention, screening, healthcare utilization, chronic disease.

CONCLUSIONS

Limited health literacy may detrimentally affect understanding and outcomes in breast surgical oncology. Identifying ways providers can improve patient understanding and utilization of health information is important, and surgeons may have a pivotal role. Further studies addressing health literacy in breast surgical oncology is needed in order to better optimize care of patients.

Misconceived expectations: Patient reflections on the total knee replacement journey

INTRODUCTION

Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey.

METHODS

Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached.

ETHICS APPROVAL

Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18).

RESULTS

In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions).

DISCUSSION AND CONCLUSION

These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

Racial Disparities in Total Knee Replacement Failure As Related to Poverty

OBJECTIVE

To determine whether racial disparities in total knee replacement (TKR) failure are explained by poverty.

METHODS

Black and white New York state residents, enrolled in a prospective single-institution TKR registry January 1, 2008 to February 6, 2012, who underwent primary unilateral TKR (n = 4,062) were linked to the New York Statewide Planning and Research Cooperative System database (January 1, 2008 to December 31, 2014) to capture revisions performed at outside institutions. Patients were linked by geocoded addresses to residential census tracts. Multivariable Cox regression was used to assess predictors of TKR revision. Multivariable logistic regression was used to analyze predictors of TKR failure, defined as TKR revision in New York state ≤2 years after surgery, or as Hospital for Special Surgery (HSS) TKR quality of life score "not improved" or "worsened" 2 years after surgery.

RESULTS

The mean ± SD age was 68.4 ± 10 years, 64% of patients were female, 8% lived in census tracts with >20% of the population under the poverty line, and 9% were black. Median follow-up time was 5.3 years. A total of 3% of patients (122 of 4,062) required revision a median 454 days (interquartile range 215-829) after surgery. TKR revision risk was higher in blacks than whites, with a hazard ratio of 1.69 (95% confidence interval 1.01-2.81), but in multivariable analysis, only younger age, male sex, and constrained prosthesis were predictors of TKR revision. TKR failure occurred in 200 of 2,832 cases (7%) with 2-year surveys. Risk factors for TKR failure were non-osteoarthritis TKR indication, low surgeon volume, and low HSS Expectations Survey score, but not black race. Community poverty was not associated with TKR revision or failure.

CONCLUSION

There was a trend toward higher TKR revision risk in blacks, but poverty did not modify the relationship between race and TKR revision or failure.

Cocreation of a digital patient health hub to enhance education and person-centred integrated care post hip fracture: a mixed-methods study protocol

INTRODUCTION

Older people with hip fractures often require long-term care and a crucial aspect is the provision of quality health information to patients and their carers to support continuity of care. If patients are well informed about their health condition and caring needs, particularly posthospital discharge into the community setting, this may support recovery and improve quality of life. As internet and mobile access reach every household, it is possible to deliver a new model of service using a digital education platform as a personal health hub where both patients and their providers of care can establish a more efficient information integration and exchange process. This protocol details proposed research, which aims to develop a 'model of care' by using a digital health solution that will allow delivery of high quality and patient-centred information, integrated into the existing process delivered within the community setting.

METHODS AND ANALYSIS

This phase of the study uses a pragmatic mixed-methods design and a participatory approach through engagement of patients, their carers and healthcare providers from multiple disciplines to inform the development of a digital health platform. Quantitative methods will explore health literacy and e-health literacy among older people with hip fractures admitted to the two public tertiary care hospitals in Adelaide, South Australia. Qualitative methods will provide an understanding of aspects of content and context required for the digital health platform to be developed in order to deliver quality health information. The study will use appropriate theoretical frameworks and constructs to guide the design, analysis and overall conduct of the research study. The scope of the study intends to ultimately empower patients and their carers to improve self-management and to better use coordinated services at the community level. This could prevent further falls including associated injuries or new fractures; reduce new hospital admissions and improve confidence and engagement by limiting the psychologically restrictive 'fear of falls'.

ETHICS AND DISSEMINATION

The study has been approved by the Human Research Ethics Committee of the Central Adelaide Local Health Network, South Australia (SA) Health, Government of South Australia and the University of Adelaide Human Research Ethics Committee. Findings from the study will be published in suitable peer-reviewed journals and disseminated through workshops or conferences.

Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study

BACKGROUND

In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients' willingness to accept nonsurgical interventions for knee OA is low. A qualitative investigation of why patients may feel that such interventions are of little value may be an important step toward increasing their use in the treatment of knee OA QUESTIONS/PURPOSES: This qualitative study was embedded in a larger study investigating patient-related factors (beliefs/attitudes toward knee OA and its treatment) and health-system related factors (access, referral pathways) known to influence patients' decisions to seek medical care. In this paper we focus on the patient-related factors with the aim of exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee OA.

METHODS

A cross-sectional qualitative study was conducted in a single tertiary hospital in Australia. Patients with endstage knee OA on the waiting list for TKA were approached during their preadmission appointment and invited to participate in one-to-one interviews. As prescribed by the qualitative approach, data collection and data analysis were performed in parallel and recruitment continued until the authors agreed that the themes identified would not change through interviews with subsequent participants, at which point, recruitment stopped. Thirty-seven patients were approached and 27 participated. Participants were 48% female; mean age was 67 years. Participants' beliefs about knee OA and its treatment were identified in the interview transcripts. Beliefs were grouped into five belief dimensions: identity beliefs (what knee OA is), causal beliefs (what causes knee OA), consequence beliefs (what the consequences of knee OA are), timeline beliefs (how long knee OA lasts) and treatment beliefs (how knee OA can be controlled).

RESULTS

All participants believed that their knee OA was "bone on bone" (identity beliefs) and most (> 14 participants) believed it was caused by "wear and tear" (causal beliefs). Most (> 14 participants) believed that loading the knee could further damage their "vulnerable" joint (consequence beliefs) and all believed that their pain would deteriorate over time (timeline beliefs). Many (>20 participants) believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage. They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs).

CONCLUSIONS

Common misconceptions about knee OA appear to influence patients' acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been "diagnosed" with "bone-on-bone" changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage. Future research involving larger, more representative samples are needed to understand how widespread these beliefs are and if/how they influence treatment decisions. In the meantime, clinicians seeking to encourage acceptance of nonsurgical interventions may consider exploring and targeting misconceptions that patients hold about the identity, causes, consequences, timeline, and treatment of knee OA.

LEVEL OF EVIDENCE

Level II, prognostic study.