Conceptualising time before surgery: the experience of patients waiting for hip replacement

Older people's experiences of hospitalization for surgical intervention for hip fracture: A systematic review

BACKGROUND

Hip fracture always requires hospitalization with high cost, which cause the complicated experiences and feelings.

OBJECTIVE

To inform pre- and in-hospital communication practices between healthcare professionals and patients through a systematic review and qualitative research that synthesizes the experiences and feelings of older patients with hip fracture during the perioperative period.

METHODS

We searched the Cochrane Library, PubMed, Web of Science, CINAHL, and three Chinese databases for relevant studies. Qualitative studies were included if they were related to the experiences and needs of hospitalization of older patients with hip fracture. Study quality was evaluated using the 2016 Joanna Briggs Institute quality evaluation criteria for qualitative research, and the results were consolidated using an thematic synthesis approach.

RESULTS

Sixteen studies were included in our meta-synthesis. We extracted 58 clear research topics. Eight new categories were formed after induction and integration, which were finally merged into three integrated results. Integration result 1: Patients suffered a large amount of physical and psychological trauma. Integration result 2: A balance of proper protection and independence for patients is required. Integration result 3: Adequate pre-discharge preparation is required.

CONCLUSIONS

Our review suggests that healthcare professionals should reduce pain catastrophizing and the fear of falling after surgery among older people with hip fracture. Furthermore, adequate pre-discharge preparation should be made jointly with patients. Meeting patients' diverse needs by various methods will promote active and healthy aging.

Better Before-Better After: A Qualitative Phenomenology Study of Older Adults' Experiences With Prehabilitation Before Total Hip Replacement

Total hip replacement is considered a successful intervention for pain relief and improved function. However, poor presurgery physical function may increase the likelihood of delayed postsurgery recovery. The purpose of this study was to describe community-dwelling older adults' experiences with a prehabilitation program (preoperative exercise) before total hip replacement. Four participants were interviewed 13 and 15 weeks postsurgery. The interviews were recorded, transcribed, and analyzed with systematic text condensation. Physical, mental, and social limitations were, to a higher or lesser degree, part of the participants' life presurgery. The results indicate that tailored close supervised training presurgery increased the participants' amount of and adherence to exercise, confidence, and sense of control. The participants had a positive experience of increased strength during the training period and gained motivation to perform progressive training. The exercise program helped the participants be physically and mentally prepared. The results indicate that close supervised prehabilitation in community-dwelling older adults undergoing total hip replacement can contribute to improved function and increase the level of activity and self-efficacy postsurgery.

A synthesis of qualitative research to understand the complexity behind treatment decision-making for osteoarthritis

Objective

Osteoarthritis is the most common joint disease with treatment involving a multidisciplinary approach with pharmacological, physical therapies and surgery as options. Qualitative research can help us to understand the complexity of managing health conditions and this understanding plays a role in good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis, including decision making about joint replacement.

Methods

We comprehensively searched 4 bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10 ​123 titles, 548 abstracts, and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world.

Results

We developed 7 themes: Becoming your own expert can be hard work; Living has become a careful balancing act; Medication is a double-edged sword; I have other things in my life to consider; You have to weigh up the odds of surgery; Surgery is the only effective option; and Surgery will give me a chance to live now. These findings have been drawn into a conceptual model reflecting a complex balancing act with tensions underpinning treatment decision making.

Conclusions

Osteoarthritis is framed as a world where patients become their own expert about their management and healthcare choices. Our conceptual model highlights key tensions underpinning treatment decision-making. These findings provide clinicians with insight of the complex nature of these decisions and how they can help patients through shared decision making.

The shadows of waiting and care: on discourses of waiting in the history of the British National Health Service

Waiting is at the centre of experiences and practices of healthcare. However, we know very little about the relationship between the subjective experiences of patients who wait in and for care, health practitioners who 'prescribe' and manage waiting, and how this relates to broader cultural meanings of waiting. Waiting features heavily in the sociological, managerial, historical and health economics literatures that investigate UK healthcare, but the focus has been on service provision and quality, with waiting (including waiting lists and waiting times) drawn on as a key marker to test the efficiency and affordability of the NHS. In this article, we consider the historical contours of this framing of waiting, and ask what has been lost or occluded through its development. To do so, we review the available discourses in the existing literature on the NHS through a series of 'snapshots' or key moments in its history. Through its negative imprint, we argue that what shadows these discourses is the idea of waiting and care as phenomenological temporal experiences, and time as a practice of care. In response, we begin to trace the intellectual and historical resources available for alternative histories of waiting - materials that might enable scholars to reconstruct some of the complex temporalities of care marginalized in existing accounts of waiting, and which could help reframe both future historical accounts and contemporary debates about waiting in the NHS.

The Relationship Between Perioperative Care Quality and Postoperative Comfort Level in Patients With Hip Replacement Surgery

PURPOSE

To examine the relationship between perioperative care quality and postoperative comfort level of patients undergoing hip replacement surgery.

DESIGN

This is a descriptive study.

METHODS

This study was conducted with 90 patients between February and September 2021 in a training and research hospital in Turkey. Data were collected from Information Form, the Good Perioperative Nursing Care Scale (for Patients) (GPNCS), and the Post Hip Replacement Comfort Scale (PHRCS).

FINDINGS

The mean age of the patients was 65.58 ± 15.10 years. The mean total scores of the patients in GPNCS and PHRCS were 134.61 ± 16.29 and 3.58 ± 0.40, respectively. In the correlation analysis, a statistically significant and positive weak relationship was determined between GPNCS and PHRCS, and as the quality of care during the surgery increases, the postoperative comfort levels increase (r = 0.253, P < .05).

CONCLUSIONS

Ensuring the comfort of patients during the surgery as well as in the pre-, intra- and postoperative period is necessary and important for the quality of care. In addition, since the quality of the care during surgery is effective on the postoperative comfort levels of the patients, quality nursing care is required pre-, intra-, and postoperative periods.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with osteoarthritis pain

ABSTRACT

Osteoarthritis pain affects the lives of a large number of people around the world. Understanding other people's experience is integral to effective care and qualitative research can have an important part to pay in education and good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis in order to incorporate this knowledge into an educational resource. We comprehensively searched four bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10123 titles, 548 abstracts and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world. We developed 7 themes from more than 600 findings: it is part of my life's tapestry; (yet) it is consuming me; it constrains my body and my occupations; I am becoming separated yet dependent; I accept, but I will not let it define me; (yet) this makes me feel less than the person I was. Our findings highlight the profound impact that osteoarthritis can have on people's lives and the struggle to hold onto a sense of self. They indicate that recognising these losses, and taking osteoarthritis seriously, is an integral part of effective healthcare. This finding may be transferable beyond this condition.

Identifying and Understanding the Non-Clinical Impacts of Delayed or Cancelled Surgery in Order to Inform Prioritisation Processes: A Scoping Review

The COVID-19 pandemic has resulted in significant delays to non-urgent elective surgery. Decision making regarding prioritisation for surgery is currently informed primarily by clinical urgency. The ways in which decision making should also consider potential social and economic harm arising from surgical delay are currently unclear. This scoping review aimed to identify evidence related to (i) the nature and prevalence of social and economic harm experienced by patients associated with delayed surgery, and (ii) any patient assessment tools that could measure the extent of, or predict, such social and economic harm. A rapid scoping review was undertaken following JBI methodological guidance. The following databases were searched in October 2020: AMED; BNI; CINAHL; EMBASE; EMCARE; HMIC; Medline; PsychINFO, Cochrane, and the JBI. A total of 21 publications were included. The findings were categorised into five themes: (i) employment, (ii) social function and leisure, (iii) finances, (iv) patients' experiences of waiting, and (v) assessment tools that could inform decision making. The findings suggest that, for some patients, waiting for surgery can include significant social, economic, and emotional hardship. Few validated assessment tools exist. There is an urgent need for more research on patients' experiences of surgical delay in order to inform a more holistic process of prioritising people on surgical waiting lists in the COVID-19 pandemic recovery stages.

Global profile of individuals undergoing total knee replacement through the PROGRESS-PLUS equity lens: Protocol for a systematic review

Background

Osteoarthritis (OA) is a heterogenous degenerative disorder often causing destructive joint changes with severe pain and functional disability. Modifiable and non-modifiable risk factors, social context and psychological factors influence the development and progression of the disease. Total knee replacement (TKR) aims at reducing pain and improving function and is more successful with pre-operative and post-operative rehabilitation. However, most international research on rehabilitation interventions is conducted in high income contexts.

Objective

The aim of our systematic review is to gain an overview of the demographic and social profiles of adults undergoing TKR for primary knee OA in lower, middle- and high-income countries through a health equity lens to inform the translation of intervention research in local contexts.

Methods

A systematic review will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Eligibility criteria include observational studies and grey literature (theses) since the beginning of the databases reporting on demographic data of adults awaiting or undergoing TKR surgery. The PROGRESS-Plus framework will be used to describe equity elements.

Results

A narrative summary and description of the global profile of individuals undergoing total knee replacement for osteoarthritis.

Conclusion

A snapshot of the global demographic and social profile of individuals receiving TKR for primary knee OA through an equity lens will shed light on the similarities and differences between individuals from different contexts. Global demographic profile information may inform or assist in the development of translational strategies for evidence-based rehabilitation.

Clinical implications

Translation of existing rehabilitation interventions to local contexts could improve pre-operative and post-operative outcomes for individuals on our surgical waiting lists.

Development of a decision analytical framework to prioritise operating room capacity: lessons learnt from an empirical example on delayed elective surgeries during the COVID-19 pandemic in a hospital in the Netherlands

OBJECTIVE

To develop a prioritisation framework to support priority setting for elective surgeries after COVID-19 based on the impact on patient well-being and cost.

DESIGN

We developed decision analytical models to estimate the consequences of delayed elective surgical procedures (eg, total hip replacement, bariatric surgery or septoplasty).

SETTING

The framework was applied to a large hospital in the Netherlands.

OUTCOME MEASURES

Quality measures impacts on quality of life and costs were taken into account and combined to calculate net monetary losses per week delay, which quantifies the total loss for society expressed in monetary terms. Net monetary losses were weighted by operating times.

RESULTS

We studied 13 common elective procedures from four specialties. Highest loss in quality of life due to delayed surgery was found for total hip replacement (utility loss of 0.27, ie, 99 days lost in perfect health); the lowest for arthroscopic partial meniscectomy (utility loss of 0.05, ie, 18 days lost in perfect health). Costs of surgical delay per patient were highest for bariatric surgery (€31/pp per week) and lowest for arthroscopic partial meniscectomy (-€2/pp per week). Weighted by operating room (OR) time bariatric surgery provides most value (€1.19/pp per OR minute) and arthroscopic partial meniscectomy provides the least value (€0.34/pp per OR minute). In a large hospital the net monetary loss due to prolonged waiting times was €700 840 after the first COVID-19 wave, an increase of 506% compared with the year before.

CONCLUSIONS

This surgical prioritisation framework can be tailored to specific centres and countries to support priority setting for delayed elective operations during and after the COVID-19 pandemic, both in and between surgical disciplines. In the long-term, the framework can contribute to the efficient distribution of OR time and will therefore add to the discussion on appropriate use of healthcare budgets. The online framework can be accessed via: https://stanwijn.shinyapps.io/priORitize/.

A sense of being rejected: Patients' lived experiences of cancelled knee or hip replacement surgery

BACKGROUND

Growing care queues, reduced access to care and cancelled surgery are realities for some patients being treated with total hip or knee replacement surgery in Sweden. Most of the patients on the waiting lists have experienced pain and limited motion for a varying period of time, with a negative effect on their everyday lives. Overbooked surgical schedules are already contributing to the lengthy waiting times, but, with the addition of cancellations, longer waiting times will increase still further and may affect patients' well-being.

METHODS

In the present study, we aimed to illuminate the experience of having planned surgery cancelled, based on narratives from 10 participants. The interview transcriptions were analysed using a phenomenological hermeneutic approach.

RESULTS

The comprehensive analyses revealed that the participants described the agony of being deselected and the additional impression of being excluded. Metaphors of being damaged and feeling physical pain were used and the interpretations referred to the cancellations as unpleasant. Additionally, the important relationship and the trust between the health workers and the patient were negatively affected by the cancellation.

CONCLUSION

After the cancellation, the participants expressed being vulnerable and from their perspective the cancelled surgery affected them deeply; in fact, much more than the healthcare workers appeared to understand. Therefore, information around the cancellation must be given respectfully and with dignity, in a dialogue between the patient and the healthcare workers. Taken together, to enable an opportunity to be involved in the continued care. The cancellations should be seen as an interruption, in which the patients' chance of living a pain-free, active life is postponed.

The burden of waiting to access pain clinic services: perceptions and experiences of patients with rheumatic conditions

BACKGROUND

Extensive waiting times before receiving services is a major barrier to adequate pain management. Waiting times may have a detrimental impact on patients' conditions and quality of life. However, there remains a lack of knowledge on the actual experiences of patients waiting to receive services, especially for those with rheumatic conditions. The present study aimed to gain an in-depth understanding of perceptions and experiences of patients with rheumatic conditions regarding access to pain clinic services. The secondary objective was to identify possible solutions to improve this access according to patients' perspectives.

METHODS

This qualitative study based on semi-structured interviews was conducted with adults with rheumatic conditions waiting to access pain clinics in the province of Quebec, Canada. Interviews were transcribed verbatim and analyzed using thematic content analysis.

RESULTS

Twenty-six participants were interviewed (22 women and 4 men; mean age 54 ± 10 years). Four main themes were identified: 1) the perception that waiting time is unacceptably long; 2) how the lack of information affects patients' experiences of waiting; 3) patients' various expectations towards the pain clinic, from high hopes to disillusionment and 4) carrying an emotional, physical and financial burden resulting from the wait. Participants reported several solutions to improve the experience of waiting, including providing information to patients, increasing resources, improving prioritization processes and care coordination, and providing alternative interventions to patients during the wait.

CONCLUSIONS

For patients with rheumatic conditions, access to pain clinic services is challenging due to extensive waiting times. The burden it imposes on them adds to the existing challenge of living with a chronic rheumatic condition. The solutions identified by participants could serve as building blocks to develop and implement measures to improve patients' experience of accessing pain-related services.

'It's all about time': Temporal effects of cancer pathway introduction in treatment and care

In the last decades, increased focus on time optimisation in healthcare services has led to introduction of new standardising technologies that alter the temporal structures of treatment-trajectories and work-practices. This paper presents a qualitative study of the temporal effects of introducing cancer pathways at a university hospital and a cancer rehabilitation centre in Denmark. Building analytically on a combination of Eviatar Zerubavel's and Norbert Elias's sociological studies on time, we show how the introduction of pathways has intensified the separation of cancer treatment and psychosocial support into two decoupled but mutually interdependent temporal orders. We furthermore demonstrate how pathway introduction has increased the focus on time as an overarching quality standard for treatment and care across organisational boundaries. Based on this analysis, we suggest that to understand current standardisation and optimisation processes and their unintended organisational effects, temporality should be treated as a research object of its own. Rather than analytically pre-empting temporal dichotomies or a priori assigning normativity to particular temporal structures, we call for thorough empirical investigation of temporal patterns in and between healthcare organisations.

Τhe multiple temporalities of deep brain stimulation (DBS) in Greece

This contribution intends to explore patients' lived experience, with a focus on the temporal dimension. On the basis of a qualitative study that led me to interview persons with Parkinson's disease (PD), caregivers, and medical professionals, I develop an empirical and philosophical investigation of the temporalities surrounding the implementation of deep brain stimulation (DBS) in Greece. I raise the issue of access to DBS medical care, and show how distinct temporalities are implied when the patients face such a matter: that of linear time, linked with the medical discourse, the bureaucratic time linked to administrative and financial hurdles in the implementation and maintenance of DBS, and the technological time of the body/technology fusion. I consider initially the impact of technology and health care settings on the lived experience of patients and the enactment of multiple bodies which are interrelated with the social world. I then expand my analysis in order to show that this experience cannot be a solipsistic one, or specific to one physician/patient relationship. It is fully socially shaped.

Framing the failure of medical implants: Media representations of the ASR hip replacements in the UK

BACKGROUND

During the twentieth century, hip replacement became one of the most popular and successful operations. In the 1990s, a new type of hip replacement namely the metal-on-metal hip resurfacing was developed. This paper draws on one of the available implants, namely the DePuy Orthopaedics' Articular Surface Replacement (ASR) hip system which was withdrawn from the market because of higher than expected rates of failure. It examines media representations on the failure of the ASR metal-on-metal hip replacement device and its subsequent withdrawal from the market.

METHODS

Drawing on content analysis this paper explores how systemic failure of the medical implant was framed and performed by press media in the UK.

RESULTS

Two narratives were particularly important in framing press media coverage of the ASR case: the role of patients as passive recipients of care and a distinction between health and disability identities as related to how individuals' narratives about the past shaped their sense of present and future. In all cases, the voice of the orthopaedic surgeons responsible for the selection and implantation of the ASR devices remains silent.

CONCLUSIONS

Press media coverage of medically induced harm in the UK is significantly less common than coverage of any other patient safety issues and public health debates. This study aims to contribute to the evidence base on how public discourse on medically induced harm becomes framed through the reported experiences of individuals in press media and also how this process influences the legitimacy of various solutions to medical errors or unanticipated outcomes.

A new integrative approach to increase quality of life by reducing pain and fear of movement in patients undergoing total hip arthroplasty: the IARA model

Total hip arthroplasty (THA) improve the patients' quality of life, and one of the most important problems after surgery is to optimize postoperative pain management. It has been shown that pain is intimately linked to the fear of movement, the so-called kinesiophobia, which can affect the entire perioperative period and quality of life in people undergoing THA. In this study, we aimed to present a new integrative approach called IARA model specifically focused on educational interventions such as knowledge and awareness of illness, guided imagery, and drawings to help the patient achieve full autonomy and confidence about the perioperative period and surgery. The Hip Injury and Osteoarthritis Outcome Score (HOOS), Tampa Scale Kinesiophobia (TSK) questionnaire, and Numeric Rating Scale 0-10 have been used to test the efficacy of IARA. The main finding in the present study was the effectiveness of IARA model in improving indexes of pain (p < 0.01) and QoL (p < 0.01) and to keep kinesiophobia levels low in patients undergoing THA.

Intra-abdominal and intra-pelvic complications following operations around the hip: causes and management-a review of the literature

Although successful and well-established procedures, hip operations whether elective or trauma are coupled with a variety of complications. Among the most uncommon complications are injuries to intra-abdominal or intra-pelvic organs which could prove potentially life-threatening. While there are various reports of such injuries in the literature, we aimed to perform a systematic review in order to examine the causes and relationships between intra-abdominal and intra-pelvic complications and the mechanism of injury, the pattern of presentation, identification, the course of management and outcomes. We identified 69 reports describing a total of 84 complications in intra-pelvic and intra-abdominal contents in 75 patients. These involved six major categories, including the intestinal tract, the urinary tract, the genital tract, the vascular system, the viscera and peripheral nerves. The most commonly injured system was the urinary (33.33%), followed by the vascular (29.76%) and the intestinal (22.62%). Among these systems, the most prevalent complications involved injury to the urinary bladder (32.14%), the large intestine (68.42%) and the external iliac artery (44%). The majority of recorded complications were postoperative with 71 incidents in 63 cases (84.52%). In intra-operative complications the most prevalent injury was due to hardware penetration (53.85%), while in postoperative it was due to hardware migration (92.06%). The management of injuries varied widely, with the most common approach being open exploration and direct repair (77.33%). The reported management outcomes included death (8%) and Girdlestone resection (2.67%), while the majority of the patients healed uneventfully (82.67%) owing mostly to immediate intervention. Despite being rare, such complications may still occur in a variety of settings and may subsequently lead to potential life-threatening situations. Thus, in order to avoid catastrophic outcomes we emphasize the need for prompt identification, immediate intervention and a multidisciplinary approach when necessary.

'Waiting for' and 'waiting in' public and private hospitals: a qualitative study of patient trust in South Australia

Background

Waiting times for hospital appointments, treatment and/or surgery have become a major political and health service problem, leading to national maximum waiting times and policies to reduce waiting times. Quantitative studies have documented waiting times for various types of surgery and longer waiting times in public vs private hospitals. However, very little qualitative research has explored patient experiences of waiting, how this compares between public and private hospitals, and the implications for trust in hospitals and healthcare professionals. The aim of this paper is to provide a deep understanding of the impact of waiting times on patient trust in public and private hospitals.

Methods

A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals). Data collection occurred in 2012–13, and data were analysed using pre-coding, followed by conceptual and theoretical categorisation.

Results

Participants differentiated between experiences of ‘waiting for’ (e.g. for specialist appointments and surgery) and ‘waiting in’ (e.g. in emergency departments and outpatient clinics) public and private hospitals. Whilst ‘waiting for’ public hospitals was longer than private hospitals, this was often justified and accepted by public patients (e.g. due to reduced government funding), therefore it did not lead to distrust of public hospitals. Private patients had shorter ‘waiting for’ hospital services, increasing their trust in private hospitals and distrust of public hospitals. Public patients also recounted many experiences of longer ‘waiting in’ public hospitals, leading to frustration and anxiety, although they rarely blamed or distrusted the doctors or nurses, instead blaming an underfunded system and over-worked staff. Doctors and nurses were seen to be doing their best, and therefore trustworthy.

Conclusion

Although public patients experienced longer ‘waiting for’ and ‘waiting in’ public hospitals, it did not lead to widespread distrust in public hospitals or healthcare professionals. Private patients recounted largely positive stories of reduced ‘waiting for’ and ‘waiting in’ private hospitals, and generally distrusted public hospitals. The continuing trust by public patients in the face of negative experiences may be understood as a form of exchange trust norm, in which institutional trust is based on base-level expectations of consistency and minimum standards of care and safety. The institutional trust by private patients may be understood as a form of communal trust norm, whereby trust is based on the additional and higher-level expectations of flexibility, reduced waiting and more time with healthcare professionals.

'Thinking that somebody's going to delay [a tonsillectomy] for one to two years is quite horrifying really': a qualitative feasibility study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 2)

OBJECTIVES

Level one evidence on the value of adult tonsillectomy versus non-surgical management remains scarce. Before embarking on a costly national randomised controlled trial, it is essential to establish its feasibility.

DESIGN

Feasibility study with in-depth qualitative and cognitive interviews.

SETTING

ENT staff and patients were recruited from nine hospital centres across England and Scotland.

PARTICIPANTS

Patients who were referred for tonsillectomy (n = 15), a convenience sample of general practitioners (n = 11) and ear, nose and throat staff (n = 22).

MAIN OUTCOME MEASURES

To ascertain whether ear, nose and throat staff would be willing to randomise patients to the treatment arms. To assess general practitioners' willingness to refer patients to the NAtional Trial of Tonsillectomy IN Adults (NATTINA) centres. To assess patients' willingness to be randomised and the acceptability of the deferred surgery treatment arm. To ascertain whether the study could progress to the pilot trial stage.

RESULTS

Ear, nose and throat staff and general practitioners were willing to randomise patients to the proposed NATTINA. Not all ENT staff were in equipoise concerning the treatment pathways. Patients were reluctant to be randomised into the deferred surgery group if they had already waited a substantial time before being referred.

CONCLUSIONS

Findings suggest that the NATTINA may not be feasible. Proposed methods could not be realistically assessed without a pilot trial. Due to the importance of the question, as evidenced by NATTINA clinicians, and strong support from ENT staff, the pilot trial proceeded, with modifications.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

The temporal properties of e-learning: an exploratory study of academics ' conceptions

Purpose

– The purpose of this paper is to present the results of an exploratory study that investigates Portuguese academics’ conceptions concerning the temporal properties of e-learning, in the context of traditional Higher Education Institutions.

Design/methodology/approach

– Grounded Theory methodology was used to systematically analyse data collected in semi-structured interviews with 62 academics. Data analysis followed the constant comparative method and its three-staged coding approach: open, axial and selective coding. Data collection and analysis developed until theoretical saturation was reached.

Findings

– Emergent academics’ conceptions concerning the temporal properties of e-learning indicate the existence of unregulated and unaccounted for dynamics, which are a direct consequence of transitioning from campus-based lecturing to teaching online using the affordances of virtual learning environments. This transition produces disruptions to established workload metrics and work patterns, as well as conflicts with dominant modes of instructional delivery that are not synchronised with the demands of online interaction and immediacy.

Originality/value

– This paper is valuable to e-learning strategists and administrators. An understanding of the temporal properties of e-learning as perceived by academics provides actionable knowledge that is directly applicable to the design of suitable work arrangements, normative frameworks and e-learning practices that address perceived time-related barriers. To mitigate the time-related conflicts and disruptions identified in the study the authors suggest the establishment of university-wide norms of virtual presence and the implementation of temporal protocols to sustain the productive engagement between instructors and learners.