Is Health Literacy Associated With Surgical Outcomes? A Systematic Review.

INTRODUCTION: Low levels of health literacy have been shown to increase healthcare utilization and negatively affect health outcomes within medical specialties. However, the relationship of health literacy with clinical, patient-centered, and process-oriented surgical outcomes is not as well understood. MATERIALS AND METHODS: We sought to systematically review the current evidence base regarding the relationship between health literacy and a range of outcomes in patients experiencing surgical care. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched six databases and then identified and extracted data from 25 cross-sectional or cohort studies deemed eligible for a systematic review. RESULTS: Among included studies, strong evidence exists to support an association between low health literacy and worse patient-centered outcomes, as well as an association between low health literacy and poorer process-oriented surgical outcomes. However, the relationship between health literacy and clinical outcomes remains unclear. CONCLUSIONS: Substantial opportunities remain to improve our understanding of the impact of health literacy on surgical outcomes. Future work should expand the range of institutional and specialized surgical settings studied, implement a standardized set of validated health literacy assessment tools, include more diverse patient populations, and investigate a comprehensive range of patient-reported outcomes.

Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis.

BACKGROUND: The pain and limitations associated with osteoarthritis of the hip and knee have a notable variation that does not correspond directly with pathophysiology. The purpose of this study is to assess the influence of location of the arthritis on pain intensity and magnitude of limitations accounting for personal and psychological factors. METHODS: One hundred and fifty four patients with osteoarthritis of the hip (41 patients) or the knee (113 patients) were enrolled in this prospective cross sectional cohort study. Patients answered questionnaires which included demographics, site of arthritis (hip or knee), laterality (unilateral or bilateral), pain intensity, Patient-Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (PROMIS PF CAT), and psychologic questionnaires including the Tampa Scale of Kinesiophobia (TSK-4), Pain Catastrophizing Scale (PCS-4), Generalized Anxiety Disorder (GAD-2) and Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS Dep CAT). Kellgren-Lawrence classification was classified by the treating surgeon. Associations of these factors with pain and function were assessed using bivariate and multivariable regression models. RESULTS: In a multivariable model accounting for potential confounding, magnitude of limitations was independently associated with years of education, work status, time spent exercising, catastrophic thinking (PCS-4), and symptoms of depression. They accounted for 50% of variability in physical function, with the major contributor being catastrophic thinking. The model for pain intensity included time spent exercising and fear of painful movement (TSK-4). Anatomic site and radiographic severity of arthritis were not associated with either physical function or pain in our patient sample. CONCLUSIONS: This study confirms that limitations and pain from osteoarthritis of the hip and knee are more closely related to personal and psychological factors, less effective cognitive coping strategies such as catastrophic thinking and kinesiophobia in particular, than to pathological and anatomical factors such as location and severity of arthritis. Care that incorporates incremental correction of common misconceptions that accompany the nociception from osteoarthritis have the potential to improve function and comfort in people with osteoarthritis. LEVEL OF EVIDENCE: Prognostic Level II.

What factors are associated with perceived disease onset in patients with hip and knee osteoarthritis?

INTRODUCTION: Newly symptomatic osteoarthritis (OA) is often misinterpreted as new pathology or injury, which is associated with pain intensity and incapability. METHODS: Adult patients with hip and knee OA completed measures of catastrophic thinking, depression, capability, symptom duration, and perceived injury. RESULTS: Symptom duration was associated with OA grade and symptoms of depression. Perceived injury was common (31%) and associated with men and knee arthritis. Capability was associated with misinterpretation of symptoms and the work status 'other,' but not radiographic severity. CONCLUSIONS: Misinterpretation of OA symptoms is common and has a greater influence on capability than radiographic grade of pathophysiology.

Comparison of an Artificial Intelligence-Enabled Patient Decision Aid vs Educational Material on Decision Quality, Shared Decision-Making, Patient Experience, and Functional Outcomes in Adults With Knee Osteoarthritis: A Randomized Clinical Trial.

Importance: Decision aids can help inform appropriate selection of total knee replacement (TKR) for advanced knee osteoarthritis (OA). However, few decision aids combine patient education, preference assessment, and artificial intelligence (AI) using patient-reported outcome measurement data to generate personalized estimations of outcomes to augment shared decision-making (SDM). Objective: To assess the effect of an AI-enabled patient decision aid that includes education, preference assessment, and personalized outcome estimations (using patient-reported outcome measurements) on decision quality, patient experience, functional outcomes, and process-level outcomes among individuals with advanced knee OA considering TKR in comparison with education only. Design, Setting, and Participants: This randomized clinical trial at a single US academic orthopedic practice included 129 new adult patients presenting for OA-related knee pain from March 2019 to January 2020. Data were analyzed from April to May 2020. Intervention: Patients were randomized into a group that received a decision aid including patient education, preference assessment, and personalized outcome estimations (intervention group) or a group receiving educational material only (control group) alongside usual care. Main Outcomes and Measures: The primary outcome was decision quality, measured using the Knee OA Decision Quality Instrument (K-DQI). Secondary outcomes were collaborative decision-making (assessed using the CollaboRATE survey), patient satisfaction with consultation (using a numerical rating scale), Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) score, consultation time, TKR rate, and treatment concordance. Results: A total of 69 patients in the intervention group (46 [67%] women) and 60 patients in the control group (37 [62%] women) were included in the analysis. The intervention group showed better decisional quality (K-DQI mean difference, 20.0%; SE, 3.02; 95% CI, 14.2%-26.1%; P < .001), collaborative decision-making (CollaboRATE, 8 of 69 [12%] vs 28 of 60 [47%] patients below median; P < .001), satisfaction (numerical rating scale, 9 of 65 [14%] vs 19 of 58 [33%] patients below median; P = .01), and improved functional outcomes at 4 to 6 months (mean [SE] KOOS JR, 4.9 [2.24] points higher in intervention group; 95% CI, 0.8-9.0 points; P = .02). The intervention did not significantly affect consultation time (mean [SE] difference, 2.23 [2.18] minutes; P = .31), TKR rates (16 of 69 [23%] vs 7 of 60 [12%] patients; P = .11), or treatment concordance (58 of 69 [84%] vs 44 of 60 [73%] patients; P = .19). Conclusions and Relevance: In this randomized clinical trial, an AI-enabled decision aid significantly improved decision quality, level of SDM, satisfaction, and physical limitations without significantly impacting consultation times, TKR rates, or treatment concordance in patients with knee OA considering TKR. Decision aids using a personalized, data-driven approach can enhance SDM in the management of knee OA. Trial Registration: ClinicalTrials.gov Identifier: NCT03956004.