Clinical Review

Patient Expectations and Total Knee Arthroplasty


 

From the Department of Physical Therapy, University of Alberta, Edmonton AB (Dr. Jones) and UT MD Anderson Cancer Center, Houston, TX (Dr. Suarez-Almazor).

 

ABSTRACT

• Objective: To discuss patient expectations of total knee arthroplasty (TKA), instruments used to measure expectations, and the association between expectations, health outcomes, and satisfaction.

• Methods: Review of the literature.

• Results: TKA is an elective surgery for patients with persistent pain and disability caused by knee arthritis. Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status, employment status, and trust in physicians. Patients have high overall expectations for recovery, particularly for pain relief and walking. Surgeons’ expectations tend to be more optimistic than patients’, although a subset of patients may have unrealistically high expectations. Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are unwilling to proceed with surgery. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minority groups. Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain.

• Conclusion: A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. A core set of reliable and valid instruments to measure expectations may encourage their routine use in both clinical and research settings.

 

Key words:  total knee arthroplasty; osteoarthritis; patient expectations; shared decision making; joint replacement .

 

Total knee arthroplasty (TKA) is an elective surgery for patients with persistent pain and disability caused by knee arthritis. It is viewed as an effective and cost-effective surgical treatment for end-stage osteoarthritis (OA) [1–4]. As the population ages and obesity rates steadily increase, so will the utilization rates for TKA, with projected demand in the United States expected to grow 673% by 2030 [5–7]. The key indicators for receiving primary TKA are end-stage OA and joint pain [8]. Although TKA is a surgical option when conservative management is exhausted, no consensus exists as to the severity of symptoms required to consider surgery [9]. Variation in the utilization of TKA exists with respect to gender, racial/ethnicity, hospital, and geography [10,11]. These differences cannot be explained by prevalence of arthritis or symptoms or by access to health care alone. Increasingly, studies have shown these variations are largely attributable to patients’ preferences, driven by their beliefs, concerns, familiarity with the procedure, and expectations, along with physician opinion [12]. While physician opinions and recommendations clearly influence patients’ decisions, they do so primarily by modulating patients’ beliefs and expectations.

Patient expectations, not only of the effectiveness of the procedure itself but also of the recovery process, influence the decision to undergo an elective surgery such as joint arthroplasty. Ideally, these expectations should be informed by evidence, but often, lack of knowledge, preconceived beliefs, and misconceptions can taint informed decision making. A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. Understanding patient expectations and factors that influence expectations provides a fuller appreciation of the outcomes that are meaningful to patients and can guide preoperative education and open dialogue with patients within a shared decision making model of care. In this paper, we discuss patient expectations of TKA, including expectations regarding outcomes and recovery, fulfillment of expectations, and the association of fulfilled expectations with satisfaction.

 

Measurement of Expectations

The construct of expectation is complex and situational. The ambiguity within the literature occurs most likely because expectations are multifaceted. Expectation involves the notion of expectancy, with respect to health care, that given events are likely to occur as a result of a medical procedure or treatment. This concept is in contrast to wants, which reflects a patient’s desire or wishes that an event will occur [13]. The term patient expectation, however, is commonly confused with patient preference or value. Preference implies a relative valuation or comparison by the patient and, unlike expectation, may not be explicitly expressed by the patient [13]. Different types of health care expectations exist that broadly relate to what patients expect regarding health care structure, process, and outcome [14].

Studies of patient expectations are diverse within the orthopedic research field and reflect differing theoretical underpinnings and lack of standardization. The lack of standardization makes measuring the complex concept of expectations challenging. While

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