Online Decision Aids for Knee Arthroplasty: An Environmental Scan

The achievement of pre-operative expectations in patients undergoing knee arthroplasty: a cohort study evaluating unique patient goals

BACKGROUND

Total knee arthroplasty (TKA) is a common procedure employed to treat end-stage osteoarthritis. While TKA is generally believed to have acceptable outcomes, many patients report pain or functional deficits not in line with their expectation following the procedure. It has been postulated that patient's pre-operative expectations regarding post-operative treatment outcomes play a significant role in satisfaction. It is therefore important to assess if the outcomes of surgery truly align with patient's individual expectations. Thus, the purpose of this study was to determine the degree to which patient expectations of TKA are achieved and the contribution of TKA to achieving patient goals one year after surgery.

METHODS

A consecutive sample of 110 patients booked for total knee arthroplasty were asked to identify their most important goals to inform the Direct Questioning of Objectives Index (DQO Index, range 0 to 1) and identify their surgical goals and grade their expectation that a knee arthroplasty would achieve each goal on an 11-point scale. One year after surgery, the DQO Index was repeated to assess their current ability to achieve each pre-operative goal, and asked to estimate the contribution of their knee arthroplasty in achieving each goal. Mean differences between baseline and one year follow-up were calculated regarding the DQO Index and expected achievement of pre-operative goals.

RESULTS

According to the DQO Index at one year, patients improved from a poor quality of life pre-operatively (mean ± standard deviation: 0.20 ± 0.18) to moderately high quality of life (mean ± standard deviation: 0.71 ± 0.21) reflecting a large improvement in ability to achieve each goal. Although achievement improved, for each goal, the patient estimates of the extent to which the knee arthroplasty had contributed to achieving the goal was lower than their initial expectation provided pre-operatively (mean difference range: 0.6 to 1.9 on an 11-point scale).

CONCLUSION

Patients undergoing TKA have high expectations that their surgery will address their primary goals. Despite surgery largely achieving these goals (improved pain and function), the extent to which the goals were achieved was lower than patients had expected pre-operatively.

Readability and Quality of Online Patient Education Materials Concerning Posterior Cruciate Ligament Reconstruction

Objective This study aimed to assess the quality of online patient educational materials regarding posterior cruciate ligament (PCL) reconstruction. Methods We performed a search of the top-50 results on Google® (terms: "posterior cruciate ligament reconstruction," "PCL reconstruction," "posterior cruciate ligament surgery," and "PCL surgery") and subsequently filtered to rule out duplicated/inaccessible websites or those containing only videos (67 websites included). Readability was assessed using six formulas: Flesch-Kincaid Reading Ease (FRE), Flesch-Kincaid Grade Level (FKG), Gunning Fog Score (GF), Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index (CLI), Automated Readability Index (ARI); quality was assessed using the JAMA benchmark criteria and recording the presence of the HONcode seal. Results The mean FRE was 49.3 (SD 11.2) and the mean FKG level was 8.09. These results were confirmed by the other readability formulae (average: GF 8.9; SMOG Index 7.3; CLI 14.7; ARI 6.5). A HONcode seal was available for 7.4 % of websites. The average JAMA score was 1.3. Conclusion The reading level of online patient materials concerning PCL reconstruction is too high for the average reader, requiring high comprehension skills. Practice implications Online medical information has been shown to influence patient healthcare decision processes. Patient-oriented educational materials should be clear and easy to understand.

Establishing a hierarchy of total knee arthroplasty patients' goals and its congruity to health professionals' perceptions: a cohort study

BACKGROUND

To formulate a hierarchy of primary goals of patients prior to total knee arthroplasty (TKA) and evaluate the agreement between patients and health professionals regarding this hierarchy of patient goals.

METHODS

The five most important goals for each of 110 consecutive patients booked for total knee arthroplasty between June and October 2019 were identified. Goals were grouped into themes and then a hierarchy formulated. This hierarchy was randomized and provided to 94 health professionals, including orthopaedic surgeons (n = 49), rheumatologists (n = 16), physiotherapists (n = 16) and general practitioners (n = 13). These health professionals ranked the provided goals based on their belief of what was most important to patients.

RESULTS

Ten overarching goals were identified, with the five most important goals to patients being improving mobility, reducing knee pain, improving daily tasks, participating in social & leisure activities and regaining knee range of motion. Health professionals ranked these goals highly similar to patients with the exceptions being that health professionals ranked quality of life near the top of the hierarchy (much higher than patients) and ranked improving mobility in the bottom half (much lower than patients). Ranking of these goals was similar between each health professional group.

CONCLUSION

Pain and mobility are the most important goals to patients, with health professionals correctly identifying these as such. However, health professionals ranked quality of life higher, and mobility lower in the hierarchy than patients. This incongruity should be considered by health professionals when educating and communicating treatment outcomes.

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.

Readability of Online Patient Education Materials for Total Joint Arthroplasty: A Systematic Review

BACKGROUND

As the demand for total joint arthroplasty continues to grow, patients increasingly turn to internet sources for accessible orthopaedic health information. We sought to evaluate the readability of online hip and knee arthroplasty patient education materials (PEMs).

METHODS

Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-P guidelines (PROSPERO registration of the study protocol: CRD42022358872, September 19th, 2022). PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were utilized to identify all studies evaluating online PEMs related to total joint arthroplasty between January 1, 2000, and August 1, 2022. The quality of studies was assessed with the Joanna Briggs Institute scale.

RESULTS

Our initial search yielded 360 publications which were then screened for appropriate studies aligned with our review's purpose. A total of eleven cross-sectional studies were included. The total sample size across the studies consisted of 662 PEMs. Five studies evaluated professional or academic orthopaedic websites, six evaluated PEMs through web engines, and three evaluated apps or commercial websites. Most included studies found PEMs to be well above the recommended 6th-grade reading level.

CONCLUSION

Arthroplasty PEMs produced by orthopaaedic websites, web searches, and apps have readability scores well above the recommended levels. Given the importance of health literacy on patient outcomes and satisfaction, work needs to be done to improve the readability of these materials.

Observing the use of knee arthroplasty appropriateness tools in clinical practice: do appropriateness criteria tools predict surgeon decision-making?

OBJECTIVE

The primary aim of this study was to evaluate the agreement between surgeons and two validated total knee arthroplasty (TKA) appropriateness tools, and secondarily to compare Australian appropriateness rates to those reported internationally.

METHODS

A consecutive sample of patients from one public hospital arthroplasty clinic and a convenience sample from private rooms of surgeons in New South Wales, Australia (n = 11), referred for surgical opinion regarding TKA were enrolled over 1 year. Surgeons applied appropriateness tools created by Escobar et al. and the American Academy of Orthopaedic Surgeons (AAOS). Correlation between the appropriateness tools and surgeon's decisions were evaluated.

RESULTS

There were 368 patients enrolled, and contrasting rates of being "appropriate" for surgery were identified between the Escobar (n = 109, 29.6%) and AAOS (n = 292, 79.3%) tools. Surgeon agreement with the Escobar tool was substantial (ĸ = 0.61, 95%CI: 0.53-0.69) compared to slight with the AAOS tool (ĸ = 0.11, 95%CI: 0.06-0.16). Of those advised against TKA (n = 179, 48.6%), the AAOS tool suggested many patients (n = 111, 62.0%) were "appropriate" compared to the Escobar tool (n = 12, 6.7%).

CONCLUSIONS

Surgeons rated patients seeking opinion for TKA as appropriate over half the time, however the AAOS tool had low correlation with surgeons as opposed to the Escobar tool. This was illustrated by both tools rating a majority of patients to be operated on as appropriate, but only the AAOS tool considering most patients not chosen for surgery to be appropriate. When comparing previously published appropriateness rates, appropriateness in Australia, USA, Spain and Qatar was found to be similar.