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 a number of conceptual models exist, Bowling and colleagues aptly recognize the multidimensionality of expectations and that no one conceptual model captures patient expectations [14]. The lack of standardization was noted in a systematic review by Haanstra and colleagues who found great variety in the definitions and measurements of expectations in studies examining their relationship with outcomes of total joint arthroplasty [15].

No gold standard measure exists for measuring patient expectations of orthopedic surgery. Zywiel’s systematic review [16] of 66 studies identified 7 validated instruments for measuring patient expectations for orthopedic surgery: of these, 2 were specific to TKA (Hospital for Special Surgery (HSS) Expectation Survey [17] and Expectation Domain of the New Knee Scoring System [18,19]), and 2 were generic to musculoskeletal conditions (Expectation domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments [20] and the Sunnybrook Surgery Expectation Survey [21]). A number of other measures used within the literature were identified; however, the psychometric properties for many of these measures were not reported and any evidence of testing and validation were lacking [16]. Some studies used a single question to measure expectations. As patient expectation is multi-dimensional, using a single item to evaluate expectations is problematic. Zywiel and others have called for a core set of reliable and valid instruments to measure expectations [14,22], which may encourage their routine use in both clinical and research settings.

Patients Expectations for TKA Recovery

Although patient concerns vary in terms of importance and severity [23], pain and physical limitations are primary concerns for patients seeking TKA. Patients have high overall expectations for recovery, particularly for pain relief and walking [24–32]. TKA is an elective surgical procedure that provides substantial pain relief and improvements in function and quality of life, with the largest gains seen within the first 6 months [33,34]. Both short-term and long-term effect sizes for pain relief and functional recovery are large, in excess of 1.0 [34]. Over 70% of patients undergoing TKA expect to be pain-free, and 35% expect to have no limitations with routine activities [24,28,31].

Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status [17], employment status, and trust in physicians [32,35]. There is, however, inconsistent evidence on associative preoperative factors of recovery expectations. While some evidence supports an association between higher expectations and younger age and greater preoperative functional limitation [26–28,32,36–38], others have reported no significant association with several preoperative factors including age, gender, and preoperative functional status [24,26,37]. Lower overall expectations [28] and lower expectations for pain relief [21] were also seen for patients with a greater number of comorbid conditions.

It may be that patients with high preoperative expectations are more optimistic, interpret their health-reported quality of life gains more liberally, and are more likely to adhere to rehabilitation treatment [24,25]. Optimism is a generalized expectancy of a positive outcome that is related to indicators of well-being [39]. Presurgical optimism was shown to be associated with less postsurgical pain and anxiety in patients undergoing total hip and knee arthroplasty [40].

In addition to general future-oriented constructs, such as optimism, treatment-specific psychological constructs, such as treatment credibility and treatment expectancy, are seen in patients with total joint arthroplasty. A strong but not redundant association is seen between treatment expectancy and treatment credibility, that is, expectations of a treatment may be related as to how credible the treatment outcomes appear [41,42]. Haanstra and colleagues advocate further clinical work to explore which factor predicts total joint arthroplasty outcomes so that patients who are at a higher risk of poor outcomes can be identified [42].