Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients.
TL;DR: Satisfaction also correlates strongly with postoperative functional scores, relief of pain, restoration of function, and success in meeting patient expectations, which are critical in maximizing patient satisfaction after THA.
Abstract: We conducted a prospective cohort study investigating the rate and predictors of dissatisfaction among patients after primary total hip arthroplasty (THA). Eight hundred fifty patients were assessed preoperatively and 1 year postoperatively using Patient Reported Outcome Measures. There was a 7% rate of dissatisfaction after THA. After univariate analysis, depression, preoperative Short Form 12 mental component score, and symptomatic arthritis of another major joint predicted dissatisfaction at 1 year, but after multivariate analysis, only symptomatic arthritis in another major joint was significant. The development of a major complication did not predict dissatisfaction. Satisfaction also correlates strongly with postoperative functional scores, relief of pain, restoration of function, and success in meeting patient expectations. Pain relief and expectation management are critical in maximizing patient satisfaction after THA.
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TL;DR: Low preoperative mental health and pain catastrophizing have an influence on outcome after TKA, and with regard to the influence of other psychological factors and for hip patients, only limited, conflicting, or no evidence was found.
367 citations
TL;DR: High fulfilments of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores, and the fulfilment of expectations was highly correlated with satisfaction.
Abstract: Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.
315 citations
TL;DR: This study provides up-to-date cost-effectiveness data for total joint replacement, which is extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.
Abstract: The aim of this study was to perform a cost–utility
analysis of total hip (THR) and knee replacement (TKR). Arthritis is
a disabling condition that leads to long-term deterioration in quality
of life. Total joint replacement, despite being one of the greatest
advances in medicine of the modern era, has recently come under
scrutiny. The National Health Service (NHS) has competing demands,
and resource allocation is challenging in times of economic restraint. Patients
who underwent THR (n = 348) or TKR (n = 323) between January and
July 2010 in one Scottish region were entered into a prospective
arthroplasty database. A health–utility score was derived from the
EuroQol (EQ-5D) score pre-operatively and at one year, and was combined
with individual life expectancy to derive the quality-adjusted life years
(QALYs) gained. Two-way analysis of variance was used to compare
QALYs gained between procedures, while controlling for baseline
differences. The number of QALYs gained was higher after THR than
after TKR (6.5 vs 4.0 years, p < 0.001). The
cost per QALY for THR was £1372 compared with £2101 for TKR. The
predictors of an increase in QALYs gained were poorer health before
surgery (p < 0.001) and younger age (p < 0.001). General health
(EQ-5D VAS) showed greater improvement after THR than after TKR
(p < 0.001). This study provides up-to-date cost-effectiveness
data for total joint replacement. THR and TKR are extremely effective
both clinically and in terms of cost effectiveness, with costs that
compare favourably to those of other medical interventions. Cite this article: Bone Joint J 2013;95-B:115–21.
295 citations
TL;DR: In hip and knee patients, preoperative depressive symptoms predicted smaller changes in different HOOS or KOOS subscales and patients were less satisfied 12 months postoperatively than patients without anxiety or depressive symptoms.
264 citations
TL;DR: Preoperative patient-reported outcome measure (PROM) scores are used to predict which patients undergoing THA are most likely to experience a clinically meaningful change in functional outcome 1 year after surgery and to support the development of patient-based informed decision-making tools.
Abstract: Despite the overall effectiveness of total hip arthroplasty (THA), a subset of patients remain dissatisfied with their results because of persistent pain or functional limitations. It is therefore important to develop predictive tools capable of identifying patients at risk for poor outcomes before surgery. The purpose of this study was to use preoperative patient-reported outcome measure (PROM) scores to predict which patients undergoing THA are most likely to experience a clinically meaningful change in functional outcome 1 year after surgery. A retrospective cohort study design was used to evaluate preoperative and 1-year postoperative SF-12 version 2 (SF12v2) and Hip Disability and Osteoarthritis Outcome Score (HOOS) scores from 537 selected patients who underwent primary unilateral THA. Minimum clinically important differences (MCIDs) were calculated using a distribution-based method. A receiver operating characteristic analysis was used to calculate threshold values, defined as the levels at which substantial changes occurred, and their predictive ability. MCID values for HOOS and SF12v2 physical component summary (PCS) scores were calculated to be 9.1 and 4.6, respectively. We analyzed the effect of SF12v2 mental component summary (MCS) scores, which measure mental and emotional health, on SF12v2 PCS and HOOS threshold values. Threshold values for preoperative HOOS and PCS scores were a maximum of 51.0 (area under the curve [AUC], 0.74; p < 0.001) and 32.5 (AUC, 0.62; p < 0.001), respectively. As preoperative mental and emotional health improved, which was reflected by a higher MCS score, HOOS and PCS threshold values also increased. When preoperative mental and emotional health were taken into account, both HOOS and PCS threshold values’ predictive ability improved (AUCs increased to 0.77 and 0.69, respectively). We identified PROM threshold values that predict clinically meaningful improvements in functional outcome after THA. Patients with a higher level of preoperative function, as suggested by HOOS or PCS scores above the defined threshold values, are less likely to obtain meaningful improvement after THA. Lower preoperative mental and emotional health decreases the likelihood of achieving a clinically meaningful improvement in function after THA. The results of this study may be used to facilitate discussion between physicians and patients regarding the expected benefit after THA and to support the development of patient-based informed decision-making tools. For example, despite significant disease, patients with high preoperative function, as measured by PROM scores, may choose to delay surgery given the low likelihood of experiencing a meaningful improvement postoperatively. Similarly, patients with notably low MCS scores might best be counseled to address mental health issues before embarking on surgery. Level III, prognostic study.
174 citations
Cites background from "Predicting dissatisfaction after to..."
...Despite the overall effectiveness of THA, a subset of patients experience persistent pain, functional limitations, and incomplete restoration of quality of life [1, 4, 38]....
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...Although the majority of patients experience meaningful clinical improvement after THA, a subset of patients do not [1, 6, 9, 23, 27, 30]....
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...The proportion of patients who are dissatisfied with their outcomes after THA range from 7% to 15% [1, 25]....
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References
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TL;DR: Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions.
Abstract: Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n=2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Components Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week)correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n=232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery for depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median=0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 107 (median=0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.
14,793 citations
"Predicting dissatisfaction after to..." refers methods in this paper
...Patients completed a Short Form 12 (SF-12) [7] and Oxford hip score (OHS) [8] functional questionnaire at this initial assessment....
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TL;DR: In this article, a 12-item questionnaire for patients having a total knee replacement (TKR) was developed and a prospective study of 117 patients before operation and at follow-up six months later, asking them to complete the new questionnaire and the form SF36.
Abstract: We have developed a 12-item questionnaire for patients having a total knee replacement (TKR). We made a prospective study of 117 patients before operation and at follow-up six months later, asking them to complete the new questionnaire and the form SF36. Some also filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon completed the American Knee Society (AKS) clinical score. The single score derived from the new questionnaire had high internal consistency, and its reproducibility, examined by test-retest reliability, was found to be satisfactory. Its validity was established by obtaining significant correlations in the expected direction with the AKS scores and the relevant parts of the SF36 and HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. We also compared change in scores with the patients' retrospective judgement of change in their condition. The effect size for the new questionnaire compared favourably with those for the relevant parts of the SF36. The change scores for the new knee questionnaire were significantly greater (p < 0.0001) for patients who reported the most improvement in their condition. The new questionnaire provides a measure of outcome for TKR that is short, practical, reliable, valid and sensitive to clinically important changes over time.
2,177 citations
TL;DR: Real improvements in the outcome of TKA must address prevention of residual pain, stiffness and swelling, and each patient's preoperative concept of the likely outcome of these procedures.
Abstract: Satisfaction with the outcome of total knee arthroplasty is highly variable, with a small but significant percentage of patients reporting dissatisfaction with the procedure. The purpose of this study was to determine which factors contribute to patient satisfaction with total knee replacement (TKR)
963 citations
"Predicting dissatisfaction after to..." refers background or result in this paper
...In keeping with other studies, we did not find that age or sex were predictive for satisfaction after joint arthroplasty [5,9-11]....
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...Most of the work on patient dissatisfaction after arthroplasty reports either combined outcomes for patients undergoing both THA and total knee arthroplasty or relates specifically to total knee arthroplasty [4-6]....
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Journal Article•
TL;DR: Patient expectations were important independent predictors of improved functional outcomes and satisfaction following TJA and greater understanding of the relationship between expectations and outcomes may improve the process of care and outcomes of TJA.
Abstract: OBJECTIVE: To evaluate the relationship between patient expectations of total joint arthroplasty (TJA) and health related quality of life plus satisfaction 6 months after surgery. Methods. This prospective cohort study included patients undergoing primary total hip (THA) and knee arthroplasty (TKA). Patients were evaluated with self-report questionnaires prior to surgery and 6 months post-surgery. Medical Outcomes Study Short Form 36 (SF-36), the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), and a satisfaction scale were used to evaluate outcomes at final followup. Multivariate regression models were used to evaluate the impact of expectations on outcomes. RESULTS: There were 102 patients with THA and 89 with TKA. Mean age was 66 years. All patients achieved significant improvements in their WOMAC and SF-36 scores following surgery. Patient expectations regarding surgery were not associated with their age, gender, index joint of surgery, marital status, or race. Expectations were not correlated with pre-operative functional health status. Expectation of complete pain relief after surgery was an independent predictor of better physical function and improvement in level of pain at 6 months post-surgery. Expectation of low risk of complications from TJA was an independent predictor of greater satisfaction. CONCLUSIONS: Patient expectations were important independent predictors of improved functional outcomes and satisfaction following TJA. Greater understanding of the relationship between expectations and outcomes may improve the process of care and outcomes of TJA.
590 citations
"Predicting dissatisfaction after to..." refers background in this paper
...Most of the work on patient dissatisfaction after arthroplasty reports either combined outcomes for patients undergoing both THA and total knee arthroplasty or relates specifically to total knee arthroplasty [4-6]....
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TL;DR: Patients who have marked functional limitation, severe pain, low mental health score, and other comorbid conditions before total knee arthroplasty are more likely to have a worse outcome at one year and two years postoperatively.
Abstract: Background: The relief of pain and the restoration of functional activities are the main outcomes of primary total knee arthroplasty for the treatment of osteoarthritis. This paper examines the preoperative predictors of pain and functional outcome at one and two years following total knee arthroplasty.
Methods: Patients were recruited for a prospective observational study of primary total knee arthroplasty for the treatment of osteoarthritis from centers in the United States, the United Kingdom, and Australia. Research assistants recruited the patients and collected the clinical history and physical examination data preoperatively and at three, twelve, and twenty-four months postoperatively. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form-36 (SF-36), and demographic data were obtained by self-administered patient questionnaires.
Results: We recruited 860 patients and obtained one-year WOMAC data on 759 patients (88%) and two-year data on 701 (82%). The mean age was seventy years, and 59% of the patients were female. Using hierarchical regression models, we found that the most significant preoperative predictors of worse scores on the pain and function domains of the WOMAC scale and on the physical functioning domain of the SF-36 at one and two years postoperatively were low preoperative scores, a higher number of comorbid conditions, and a low SF-36 mental health score. After adjusting for these predictors, we found that the functional status of the patients from the United Kingdom was significantly worse than that of the patients from the other countries and the difference was clinically important at both the one-year and two-year follow-up examination (p < 0.0005). The mean WOMAC pain scores for the three countries were not significantly different at one year, and, although they were significantly different at two years (p = 0.025), the difference was not clinically important.
Conclusions: Patients who have marked functional limitation, severe pain, low mental health score, and other comorbid conditions before total knee arthroplasty are more likely to have a worse outcome at one year and two years postoperatively. After adjusting for these predictors, it was found that patients from the United Kingdom had significantly worse functional outcomes but similar pain relief compared with those from the United States and Australia.
Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.
578 citations
"Predicting dissatisfaction after to..." refers background or result in this paper
...Preoperative mental health has been closely examined as a potential predictor of satisfaction with THA [12,13] and total knee arthroplasty [14-16]....
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...Similar findings have been established for total knee arthroplasty [14]....
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