Patient Expectations and Total Knee Arthroplasty

Shared Decision Making

The shared decision making process, in which the patient and physician share responsibility and actively participate in the clinical decision making process [71], may help in ensuring that patients’ expectations are met. Shared decision making requires eliciting patients’ preferences and values, providing clear information on the processes that will occur during surgery, recovery, rehabilitation, and in the longer phase of recovery, and what realistic outcomes can be expected. While a more “paternalistic” approach predominated in earlier years, the current trends indicate greater patient involvement in decision making with the surgeon, with open discussion of patient goals and expectations [71]. This approach also aids patients in their preparation for the recovery and rehabilitation stages, which can be challenging, especially if they are unaware as to what to expect. Patient expectations are more likely to be met when there is shared decision making and patients have been given relevant information and understand what is a reasonable outcome. While a shared decision making approach is advocated within orthopedics [72], patient expectations are largely not measured in the clinical setting.

Patient education is an integral component of assisting patients to make informed decisions; however, it is unknown whether education alone can modify expectations. Educational approaches can include group classes, videos, and written materials [73]. Limited evidence from a randomized controlled trial suggests that preoperative expectations can be modified by preoperative education classes by decreasing the number of expectations and having more expectations in agreement with the surgeons’ expectations [29]. Mancuso and colleagues, who looked at whether a preoperative education session could modify expectations found that larger changes in expectations were seen with those patients who had greater baseline expectation scores, worse pain and function, and were older [29]. Others have also reported that preoperative education reduces anxiety by providing patients with an understanding of what to expect [74,75]. An assumption is that expectations can be changed by improving knowledge, which underscores the need for relevant meaningful education to increase knowledge and instill realistic expectations. Others have surmised there is a proportion of patients who will continue to have unexpectedly high unrealistic expectations regardless of educational session [31,37]. This would suggest that education is not the only approach to modify expectations but rather different strategies may need to be implemented for a certain subsets of patients with unrealistic expectations.

Conclusion

Patient expectation is an important element to be considered in shared clinical decision making, as it can influ-ence preferences and subsequent satisfaction. Patients considering TKA have specific needs and expectations that they presume will be addressed with the surgery. If these are realistic, they can be met, and will result in greater patient satisfaction and better ongoing adherence to health care recommendations [76]. While much work has been conducted in identifying which patient characteristics may influence health expectations, additional research is needed to further determine how to shape expectations within a realistic, achievable framework. While traditional patient education is an important element to enhance knowledge, the limited available evidence suggests it is not sufficiently effective on its own. Other strategies such as use of individualized decision aids, provision of peer support, and enhanced provider-patient communication have been effective in many areas of health care and warrant evaluation in this field.

Corresponding author: Allyson Jones, PhD, Rm 2-50, Corbett Hall, University of Alberta, Edmonton, Alberta Canada T6G 2G4, cajones@ualberta.ca.

Financial disclosures: None.

Author contributions: conception and design, CAJ, MES; analysis and interpretation of data, MES; drafting of article, CAJ, MES; critical revision of the article, CAJ, MES; collection and assembly of data, CAJ.