The Impact of Preoperative Education on Patients Undergoing Elective Total Hip and Knee Arthroplasty: The Relationship Between Patient Education and Psychosocial Factors

Preoperative Education Prior to Hip or Knee Arthroplasty Is Associated With Home Discharge but Not Reduced Length of Stay

Background

Increasing numbers of patients are undergoing total joint arthroplasty as a treatment for osteoarthritis, which can be an anxiety-provoking experience. Setting expectations through a preoperative physical therapy (pre-op PT) session can alleviate some of these stressors, potentially decrease hospital length of stay (LOS), and promote home discharge.

Purpose

We sought to determine whether attending a pre-op PT session is associated with decreased hospital LOS and home discharge in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients.

Methods

A retrospective cohort study was performed of 20,822 patients who underwent THA or TKA between January 2020 and December 2023. Pre-op PT attendance and covariates, including patient demographics and clinical data, were collected and analyzed for association with LOS and discharge disposition.

Results

Unadjusted univariate analysis revealed that THA and TKA patients who received pre-op PT had a significantly lower average LOS and were more likely to be discharged home. Our multivariate regression model showed that pre-op PT was not significantly associated with LOS in both groups but was significantly associated with home discharge among THA patients.

Conclusions

Our retrospective study of the effect of pre-op PT education on LOS and discharge disposition for elective THA and TKA patients found different results in univariate and multivariate analysis. Further study is needed to confirm the association found on multivariate analysis between pre-op PT and home discharge in THA patients.

Does Participation in Virtual or In-Person Preoperative Education Relate to Reduced Length of Stay After Total Joint Arthroplasty?

Background

Advancements in surgical procedures for total joint arthroplasty (TJA) have resulted in more effective procedures with more rapid recovery. To prepare patients for surgery, many organizations offer a preoperative "joint class," which has been associated with reduced length of stay (LOS). Virtual modes of education are increasingly favored for those having TJA.

Purpose

To determine whether participation in an individually administered preoperative educational session ("Prehab") relates to reduced LOS or increased likelihood of same-day discharge (SDD) for those undergoing TJA. Additionally, to establish whether and the virtual mode of education provision is superior or inferior to the in-person mode with regards to LOS benefits.

Methods

The author conducted a case-control study of 2532 patients who had a primary or revision TJA between January 2022 and August 2022 at a single institution. Data were obtained from the electronic medical record. A total of 1118 patients attended Prehab; 1414 patients did not. Patients were included if they were over the age of 18 and had a total hip arthroplasty (THA) or total knee arthroplasty (TKA) during the study period. T-tests, chi-square χ2 tests, and binomial logistic regression were used to evaluate the LOS and SDD outcomes for those who participated in Prehab compared with those who did not.

Results

Those receiving Prehab in any form had shorter LOS than those who had not. Those receiving virtual Prehab had the shortest LOS. There was no difference in the rate of SDD for outpatient-class patients.

Conclusion

Preoperative education is associated with LOS benefits to patients undergoing TJA. The virtual mode of education provision is at minimum non-inferior, and may be superior, to the in-person mode. The lack of statistically significant between-group differences for SDD outcomes may be explained by a lack of SDD-specific educational content provided during Prehab.

Synthesis of 'joint class' curricula at high volume joint replacement centres and a preliminary model for development and evaluation

RATIONALE

Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation.

OBJECTIVE

We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature.

METHODS

We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems.

RESULTS

We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction).

CONCLUSION

Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating Resource Utilization for In-Person and Virtual Joint Classes in Total Joint Arthroplasty: An Analysis of Attendance Patterns at a Large Metropolitan Health System

BACKGROUND

Provider-run "joint classes" educate total joint arthroplasty (TJA) patients on how to best prepare for surgery and maximize recovery. There is no research on potential healthcare inequities in the context of joint classes or on the impact of the recent shift toward telehealth due to coronavirus disease 2019 (COVID-19). Using data from a large metropolitan health system, we aimed to (1) identify demographic patterns in prepandemic joint class attendance and (2) understand the impact of telehealth on attendance.

METHODS

We included data on 3,090 TJA patients from three centers, each with a separately operated joint class. Attendance patterns were assessed prepandemic and after the resumption of elective surgeries when classes transitioned to telehealth. Statistical testing included standardized differences (SD > 0.1 indicates significance) and a multivariate linear regression.

RESULTS

The in-person and telehealth attendance rates were 69.9% and 69.2%, respectively. Joint class attendance was significantly higher for non-White, Hispanic, non-English primary language, Medicaid, and Medicare patients (all SD > 0.1). Age was a determinant of attendance for telehealth (SD > 0.1) but not for in-person (SD = 0.04). Contrastingly, physical distance from hospital was significant for in-person (SD > 0.1) but not for telehealth (SD = 0.06). On a multivariate analysis, distance from hospital (P < .05) and telehealth (P < .0001) were predictors of failed class attendance.

CONCLUSION

This work highlights the relative importance of joint classes in specific subgroups of patients. Although telehealth attendance was lower, telehealth alleviated barriers to access related to physical distance but increased barriers for older patients. These results can guide providers on preoperative education and the implementation of telehealth.

Indicators and predictors modifiable by the nursing department during the preoperative period: A scoping review

AIM AND OBJECTIVES

The aim of this study is to identify preoperative indicators and/or predictors of complications or inefficiencies in the surgical process that can be modified within nursing practice.

BACKGROUND

Due to rapid sociodemographic and technological change, the global demand for surgical attention is rising exponentially, requiring new strategies for optimisation and sustainability in perioperative care.

DESIGN

We conduced the scoping review using the methodology recommended by the Joanna Briggs Institute supported with The PAGER framework and guided by the PRISMA-ScR Checklist.

METHODS

Four databases (CINAHL, MEDLINE, SCOPUS and PUBMED) were examined to extract relevant published results for elective surgery on adult patients during the period 2011-2021. This process identified 609 records. Exclusion criteria were applied, and the sample was then evaluated with the Quality Assessment Tool for Studies with Diverse Designs (QATSDD), after which 15 studies remained.

RESULTS

The following preoperative indicators and/or predictors were considered: (1) Anxiety; (2) Pain; (3) Health education, knowledge and training; (4) Satisfaction; (5) Management/organisation (including costs, resources used/available, organisational issues, hospital stay (preoperative), standardisation and protocolisation.

CONCLUSION

The identification of five indicators and/or predictors of complications or inefficiencies in the surgical process, which can be modified by nursing, allows the effective application of interventions in the preoperative phase, optimising care and improving health outcomes.

RELEVANCE TO CLINICAL PRACTICE

The development and implementation of specific nursing skills in the preoperative phase are essential to optimise the surgical process.

The effect of video-assisted discharge education after total hip replacement surgery: a randomized controlled study

This study aimed to investigate the effect of a video-assisted discharge education program on activities of daily living, functionality, and patient satisfaction following total hip replacement (THR) surgery. This study included 31 patients who were randomly divided into the physiotherapy group (n = 18), and the video-assisted discharge education (VADE) group (n = 13). Both groups received a physiotherapy program. The VADE group was also received the VADE program. Face-to-face instruction was used in all of the educational programs. There was a significant difference in favor of the VADE group in Harris Hip Score, Nottingham Extended Activities of Daily Living Scale's movement score, Tampa Scale of Kinesiophobia, Patient Satisfaction Questionnaire (p < 0.05). There was a significant difference between groups on resting pain levels in the first week and on resting and activity pain levels in the third month in favor of the VADE group (p < 0.05). The results of this study demonstrated that VADE can be effective in improving patient satisfaction and functionality, reducing pain and kinesiophobia following THR.

Overcoming fear of movement resulting from knee replacement; strategies used by patients: An interview study

BACKGROUND AND AIMS

Fear of movement is among the main concerns of patients following knee replacement surgery and a determining factor in the success of surgery. The strategies adopted by patients to overcome this fear have not yet been identified, but once pin pointed, these strategies can be strengthened and modified through intervention. The aim of the present study was to explore the personal strategies adopted by patients following knee replacement to overcome fear of movement.

MATERIALS AND METHODS

Interviews were conducted with 15 patients who had undergone knee replacement, selected by purposive sampling. Data were collected through in-depth semi-structured interviews and analyzed using inductive content analysis.

RESULTS

The patients' strategies as depicted in their narratives were classified into three categories: 1) Movement based on awareness; 2) Movement based on support; and 3) Movement based on hope. These three categories are described in eight subcategories and show what strategies the patients used to overcome their fear of movement.

CONCLUSION

These findings can help to increase awareness about strategies to overcome fear of movement in patients following knee replacement and to develop and support tailored treatment strategies with the aim of reducing such fear of movement and increasing physical activity among the patients.

Total Knee Arthroplasty in the Ambulatory Surgery Center Setting: Best Practices for Cost Containment and Clinical Care Delivery

As the current population continues to increase in age, so does the degeneration of the musculoskeletal system and the development of knee osteoarthritis. Total knee arthroplasty (TKA) will be the treatment of choice when it comes to improving physical function and decreasing pain associated with osteoarthritis of the knee. The global push for more cost-effective healthcare services has led to new models of care and payment delivery methods such as performing TKA in the ambulatory surgery center (ASC) setting. With deeply invasive surgical procedures such as TKA being done in the ASC setting, orthopaedic nurses must be mindful of best practices that will promote quality and safety while considering the importance of using current evidence to guide nursing practice when promoting appropriate patient selection and effective patient education of self-management of postoperative care pertaining to TKA being performed in the ASC setting. This is critical to consider during a time when financial profits in the ASC setting may take a front seat to the delivery of high-quality and safe patient care.

Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients?

BACKGROUND

Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use.

QUESTIONS/PURPOSES

(1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA?

METHODS

In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05.

RESULTS

THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325).

CONCLUSION

Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area.

LEVEL OF EVIDENCE

Level III, therapeutic study.