Patient acceptable symptom state (PASS): thresholds for the EQ-5D-5L and Oxford hip and knee scores for patients with total hip and knee replacement.

PURPOSE: To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12 months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS). METHODS: We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12 months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index. RESULTS: Five hundred forty-two surgical patients (mean age, 64 years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12 months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12 months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12 months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best). CONCLUSION: PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

Relationship Between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One-Year Follow-Up.

OBJECTIVE: To determine the relationship between patients' preoperative readiness for total knee arthroplasty (TKA) and surgical outcome at 1 year post-TKA. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) who were ≥30 years and were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who underwent primary unilateral TKA completed questionnaires prior to TKA to assess pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical disability using the Knee Injury and Osteoarthritis Outcome Score physical function short form, perceived arthritis coping efficacy, general self-efficacy, depressed mood using the Patient Health Questionnaire 8, body mass index, comorbidities, and TKA readiness (patient acceptable symptom state; willingness to undergo TKA); these same individuals also completed the above questionnaires 1 year post-TKA to assess surgical outcomes. A good TKA outcome was defined as an individual having improved knee symptoms, measured using the Osteoarthritis Research Society International-Outcome Measures in Rheumatology responder criteria, and overall satisfaction with results of the TKA. Poisson regression with robust error estimation was used to estimate the relative risk (RR) of a good outcome for exposures, before and after controlling for covariates. RESULTS: Of 1,272 TKA recipients assessed at 1 year post-TKA, 1,053 with data for the outcome assessed in the study were included (mean ± SD age 66.9 ± 8.8 years; 58.6% female). Most patients (87.8%) were definitely willing to undergo TKA and had "unacceptable" knee symptoms (79.7%). Among patients who underwent TKA, 78.1% achieved a good outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms, and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with a greater likelihood of a good TKA outcome, with adjusted RRs of 1.18 (95% confidence interval [95% CI] 1.04-1.35) and 1.14 (95% CI 1.02-1.27), respectively. CONCLUSION: Among patients who underwent TKA for knee OA, patients' psychological readiness for TKA and willingness to undergo TKA were associated with a greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate the use of TKA.

Patients' Preoperative Expectations of Total Knee Arthroplasty and Satisfaction With Outcomes at One Year: A Prospective Cohort Study.

OBJECTIVE: To assess the relationship between patients' expectations for total knee arthroplasty (TKA) and satisfaction with surgical outcome. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) ages ≥30 years who were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess TKA expectations (17-item Hospital for Special Surgery [HSS] TKA Expectations questionnaire) and contextual factors (age, sex, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Knee Injury and Osteoarthritis Outcome Score physical function short form [KOOS-PS], 8-item Patient Health Questionnaire depression scale, body mass index [BMI], comorbidities, and prior joint replacement), and 1-year post-TKA to assess overall satisfaction with TKA results. Using multivariate logistic regression, we examined the relationship between TKA expectations (HSS TKA outcomes considered to be very important) and postoperative satisfaction (very satisfied versus somewhat satisfied versus dissatisfied). Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: At 1 year, 1,266 patients with TKA (92.1%) reported their TKA satisfaction (mean ± SD age 67.2 ± 8.8 years, 60.9% women, and mean BMI 32.6 kg/m2 ); 74.7% of patients were very satisfied, 17.1% were somewhat satisfied, and 8.2% were dissatisfied. Controlling for other factors, an expectation of TKA to improve patients' ability to kneel was associated with lower odds of satisfaction (adjusted OR 0.725 [95% CI 0.54-0.98]). An expectation of TKA to improve psychological well-being was associated with lower odds of satisfaction for individuals in the lowest tertile of pre-TKA KOOS-PS scores (adjusted OR 0.49 [95% CI 0.28-0.84]), but higher odds for those in the highest tertile (adjusted OR 2.37 [95% CI 1.33-4.21]). CONCLUSION: In patients with TKA, preoperative expectations regarding kneeling and psychological well-being were significantly associated with the level of TKA satisfaction at 1 year. Ensuring that patients' expectations are achievable may enhance appropriate provision of TKA.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement.

PURPOSE: To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery. RESULTS: The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR. CONCLUSIONS: Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

Comparing the validity and responsiveness of the EQ-5D-5L to the Oxford hip and knee scores and SF-12 in osteoarthritis patients 1 year following total joint replacement.

PURPOSE: (1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12 in osteoarthritis patients undergoing total hip (THR) or knee (TKR) replacement surgery; (2) to compare distribution and anchor-based methods of assessing responsiveness. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR and 1 year post-surgery. We assessed effect size (ES), standardized response mean (SRM), and standard error of measurement (SEM). Minimum important difference (MID) was the mean change in patients reporting somewhat better in hip or knee, health in general, and those who were satisfied with surgery (5-point scales). Responders were compared using MID versus 1 and 2SEM. RESULTS: The sample of 537 (50% TKR) was composed of 56% female with a mean age of 64 years (SD 10). EQ-5D-5L ES was 1.86 (THR) and 1.19 (TKR) compared to 3.00 and 2.05 for Oxford scores, respectively. MID for the EQ-5D-5L was 0.22 (THR) and 0.20 (TKR) for patients who rated their hip or knee as somewhat better. There was a wide variation in the MID and the percentage of responders, depending on the joint, method of assessment, and the outcome measure. The percent agreement of responder classification using 2SEM vs. MID ranged from 79.6 to 99.6% for the EQ-5D-5L and from 69.4 to 94.8% for the Oxford scores. CONCLUSIONS: Responsiveness of the EQ-5D-5L was acceptable in TKR and THR. Caution should be taken in interpreting responder to TJR based on only one method of assessment.

Reliability and validity of the EQ-5D-5L compared to the EQ-5D-3L in patients with osteoarthritis referred for hip and knee replacement.

PURPOSE: To assess the test-retest reliability of the EQ-5D-5L (5L) and compare the validity of the 5L and EQ-5D-3L (3L) in osteoarthritis patients referred to an orthopaedic surgeon for total joint replacement. METHODS: We mailed questionnaires to 306 consecutive patients following referral and a second questionnaire after 2 weeks to assess reliability. Questionnaires included the 5L, EQ-VAS, Short Form-12, Oxford hip and knee scores, pain VAS, and the 3L. We compared the ceiling effect, redistribution properties, convergent and discriminant validity, and discriminatory power of the 5L and 3L. RESULTS: We obtained 176 respondents (response rate 58 %), 60 % female, 64 % knee patients, mean age 65 years (SD 11), with no significant differences between responders versus non-responders. Intraclass correlation coefficients were 0.61-0.77 for the 5L dimensions and 0.87 for the 5L index. For the 3L, most patients used level 2 (some/moderate problems) for mobility (87 %), usual activities (78 %), and pain/discomfort (71 %). In comparison, 5L responses were spread out with only 52, 42, and 50 %, respectively, using the middle level. All convergent validity coefficients were stronger with the 5L (Spearman coefficients 0.51-0.75). Absolute informativity (Shannon's index) showed higher results for all dimensions of the 5L compared with the 3L (average difference 0.74). Relative informativity (Shannon's evenness index) showed an increase from the 3L to the 5L in mobility, usual activities, and pain/discomfort. CONCLUSIONS: The 5L provided stronger validity evidence than the 3L, especially for dimensions relevant to this patient population-mobility, usual activities, and pain/discomfort.

You'll know when you're ready: a qualitative study exploring how patients decide when the time is right for joint replacement surgery.

BACKGROUND: While some studies have identified patient readiness as a key component in their decision whether to have total joint replacement surgery (TJR), none have examined how patients determine their readiness for surgery. The study purpose was to explore the concept of patient readiness and describe the factors patients consider when assessing their readiness for TJR. METHODS: Nine focus groups (4 pre-surgery, 5 post-surgery) were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for TJR or had undergone TJR. The method of analysis was qualitative thematic analysis. RESULTS: There were 65 participants, 66% female and 34% male, 80% urban, with an average age of 65 years (SD 10). Readiness reflected both the surgeon's advice that the patient was clinically ready for surgery and the patient's feeling that they were both mentally and physically ready for surgery. Mental readiness was described as an internal state or feeling of being ready or prepared while physical readiness was described as being physically fit and in good shape for surgery. Factors associated with readiness included: 1) pain: its severity, the ability to cope with it, and how it affected their quality of life; 2) mental preparation; 3) physical preparation; 4) the optimal timing of surgery, including age, anticipated rate of deterioration, prosthesis lifespan and the length of the waiting list. CONCLUSIONS: Patient readiness should be assessed prior to TJR. By assessing patient readiness, health professionals can elucidate and deal with concerns and fears, understand and calibrate expectations, assess coping strategies, and use this information to help determine optimal timing, both before and after the surgical consultation.

Patient factors in referral choice for total joint replacement surgery.

BACKGROUND: Although the option of next available surgeon can be found on surgeon referral forms for total joint replacement surgery, its selection varies across surgical practices. OBJECTIVES: Objectives are to assess the determinants of (a) a patient's request for a particular surgeon; and (b) the actual referral to a specific versus the next available surgeon. METHODS: Questionnaires were mailed to 306 consecutive patients referred to orthopedic surgeons. We assessed quality of life (Oxford Hip and Knee scores, Short Form-12, EuroQol 5D, Pain Visual Analogue Scale), referral experience, and the importance of surgeon choice, surgeon reputation, and wait time. We used logistic regression to build models for the 2 objectives. RESULTS: We obtained 176 respondents (response rate, 58%), 60% female, 65% knee patients, mean age of 65 years, with no significant differences between responders versus nonresponders. Forty-three percent requested a particular surgeon. Seventy-one percent were referred to a specific surgeon. Patients who rated surgeon choice as very/extremely important [adjusted odds ratio (OR), 6.54; 95% confidence interval (CI), 2.57-16.64] and with household incomes of $90,000+ versus <$30,000 (OR, 5.74; 95% CI, 1.56-21.03) were more likely to request a particular surgeon. Hip patients (OR, 3.03; 95% CI, 1.18-7.78), better Physical Component Summary-12 (OR, 1.29; 95% CI, 1.02-1.63), and patients who rated surgeon choice as very/extremely important (OR, 3.88; 95% CI, 1.56-9.70) were more likely to be referred to a specific surgeon. CONCLUSIONS: Most patients want some choice in the referral decision. Providing sufficient information is important, so that patients are aware of their choices and can make an informed choice. Some patients prefer a particular surgeon despite longer wait times.

The importance of patient expectations as a determinant of satisfaction with waiting times for hip and knee replacement surgery.

OBJECTIVES: The disconfirmation model hypothesizes that satisfaction is a function of a perceived discrepancy from an initial expectation. Our objectives were: (1) to test the disconfirmation model as it applies to patient satisfaction with waiting time (WT) and (2) to build an explanatory model of the determinants of satisfaction with WT for hip and knee replacement. METHODS: We mailed 1000 questionnaires to 2 random samples: patients waiting or those who had received a joint replacement within the preceding 3-12 months. We used ordinal logistic regression analysis to build an explanatory model of the determinants of satisfaction. RESULTS: Of the 1330 returned surveys, 1240 contained patient satisfaction data. The sample was 57% female; mean age was 70 years (SD 11). Consistent with the disconfirmation model, when their WTs were longer than expected, both waiting (OR 5.77, 95% CI 3.57-9.32) and post-surgery patients (OR 6.57, 95% CI 4.21-10.26) had greater odds of dissatisfaction, adjusting for the other variables in the model. Compared to those who waited 3 months or less, post-surgery patients who waited 6 to 12 months (OR 2.59, 95% CI 1.27-5.27) and over 12 months (OR 3.30, 95% CI 1.65-6.58) had greater odds of being dissatisfied with their waiting time. Patients who felt they were treated unfairly had greater odds of being dissatisfied (OR 4.74, 95% CI 2.60-8.62). CONCLUSIONS: In patients on waiting lists and post-surgery for hip and knee replacement, satisfaction with waiting times is related to fulfillment of expectations about waiting, as well as a perception of fairness. Measures to modify expectations and increase perceived fairness, such as informing patients of a realistic WT and communication during the waiting period, may increase satisfaction with WTs.

A bird can't fly on one wing: patient views on waiting for hip and knee replacement surgery.

OBJECTIVES: To obtain patients' perspectives on acceptable waiting times for hip or knee replacement surgery. METHODS: A questionnaire with both open- and close-ended items was mailed to 432 consecutive patients who had hip or knee replacement surgery 3-12 months previously in Saskatchewan, Canada. A content analysis was used to analyse the text data from the open-ended questions. RESULTS: The sample of 303 (response rate 70%) was 59% female with a mean age of 70 years (SD 11). The median waiting time from the decision date to surgery was 17 weeks. Individuals who rated their waiting time very acceptable (48%) had a median waiting time of 13 weeks compared with a median waiting time of 22 weeks for those who rated it unacceptable (23%). The two most common determinants of acceptability were patient expectations and pain and its impact on patient quality of life. The median maximum acceptable waiting time was 13 weeks and median ideal waiting time, 8.6 weeks. Seventy-nine per cent felt that those in greater need (higher severity) should go before them on the waiting list. Patient ratings of maximum acceptable waiting time were based on: pain and loss of mobility, time needed to prepare for surgery, and severity at the time of seeing the surgeon. In consideration of changing their surgeon to one with a shorter waiting list, 68% would not. CONCLUSIONS: Patient views on waiting times are not only related to quality of life issues, but also to prior expectations and notions of fairness and priority. Understanding patient views on waiting for surgery has implications for better management of waiting times and experiences for joint replacement.

Patient and surgeon views on maximum acceptable waiting times for joint replacement.

OBJECTIVE: To assess patient and surgeon views on maximum acceptable waiting times (MAWT) for hip and knee replacement, their determinants and their relationship to levels of urgency based on the Western Canada Waiting List Priority Criteria Score (PCS). METHODS: At the decision date for surgery, orthopaedic surgeons assessed consecutive patients with the PCS and MAWT. Patients were surveyed 3-12 months post-surgery for MAWT and potential determinants. RESULTS: The patient sample of 208 was 56% female, mean age 69 years (SD 11). Mean MAWT for patients was 18 weeks (SD 11) and for surgeons, 17 weeks (SD 11). Median MAWT for three levels of urgency (PCS) ranged from 13-17 weeks (patients) and 9-26 weeks (surgeons). Patient MAWT was unrelated to the surgeon-rated measures: MAWT (r=.05) and the PCS (r=-.10). Multiple regression analysis showed that males, knee vs. hip replacement, a longer waiting time and a perception of fairness in regard to waiting time were significant predictors of longer patient MAWT. Knee replacement, a better ability to walk without significant pain and less potential for progression of the disease were significant predictors of longer surgeon MAWT. CONCLUSIONS: Patient and surgeon perspectives on MAWT are important to the development of waiting time benchmarks. Benchmarks based on levels of urgency ensure a more transparent and fair process for waiting time management. Knowledge of determinants of MAWT should inform better management of waiting time and access, by understanding the basis of patient and physician views on acceptable waiting times.

Patient and physician perspectives of maximum acceptable waiting times for cataract surgery.

BACKGROUND: Lengthy waiting times for cataract surgery are an important issue in countries with publicly funded health care systems. To improve the fairness, timeliness, and certainty of waiting-time management, the Western Canada Waiting List Project has developed priority criteria scores (PCSs) related to urgency and linked to maximum acceptable waiting times (MAWTs). The purpose of our study was to compare patient and physician perspectives of MAWT for different levels of urgency. A second aim was to assess the determinants of patient and surgeon perspectives on MAWT. METHODS: Ophthalmologists assessed consecutive patients waitlisted for cataract surgery. Data included a MAWT, a visual analogue scale of urgency (VAS urgency), and the cataract PCS. Patients were mailed questionnaires to assess their perspectives of MAWT and VAS urgency. They were also sent a measure of visual function called the Visual Function Assessment. We used hierarchical linear regression to assess the determinants of MAWT. RESULTS: The mean age of the 213 patients was 73.9 years; 56.8% were female and 71.8% were booked for first eye surgery. Physician-rated MAWT was significantly longer than patient-rated MAWT (mean 15.1 vs. 9.9 weeks). Median physician MAWTs ranged from 12 (most urgent) to 20 (least urgent) weeks, and patient MAWTs, from 4 to 8 weeks. A 3-step hierarchical linear regression model showed that, after adjusting for age and sex, the priority criteria added significantly to the surgeon model (R2 change = 0.22). Significant predictors were ocular comorbidity, impairment in visual function, and ability to work or live independently or care for dependents. After the addition of VAS urgency, the final model explained 42% of the variance in surgeon MAWT. Significant predictors were age-related macular degeneration and VAS urgency. A 4-step hierarchical regression model for patient MAWT showed that after step 2, sex and visual acuity in the nonsurgery eye were significant predictors. The final model accounted for 11% of the variance in patient MAWT. Significant predictors were sex (males had lower MAWT) and VAS urgency. INTERPRETATION: Patient and physician views on MAWT differ, yet both are critical to a fair process for developing standardized waiting times related to levels of urgency. Results from this study provide initial inputs to the formulation of benchmark waiting times for different levels of the cataract PCS.

The prioritization of patients on waiting lists for cataract surgery: validation of the Western Canada waiting list project cataract priority criteria tool.

PURPOSE: To assess the validity of the Cataract Priority Criteria Score (PCS), developed by the Western Canada Waiting List (WCWL) Project to determine patient prioritization for cataract surgery. METHODS: Ophthalmologists assessed consecutive patients with the PCS and a visual analogue scale of urgency (VAS Urgency). Patients were mailed questionnaires pre- and post-surgery. Outcome measures were the Visual Function Assessment (VFA), EuroQol (EQ-5D), and best-corrected visual acuity. RESULTS: The sample of 253 patients was 58% female (mean age, 73.7 years); 166 completed pre-and post-surgery VFA. The correlation of the PCS and VAS Urgency was 0.65 (p = 0.000). Adjusting for age, first or second eye surgery, and post-operative complication, the PCS predicted improvement in the VFA and visual acuity (p < .05). CONCLUSIONS: These data provide some evidence to support the convergent and predictive validity of the PCS. Multiple patient outcomes should be used in the evaluation of the validity of priority scores.

Prioritization of patients on scheduled waiting lists: validation of a scoring system for hip and knee arthroplasty.

INTRODUCTION: The hip and knee replacement priority criteria tool (HKPT) is 1 of 5 tools developed by the Western Canada Waiting List Project for setting priorities among patients awaiting elective procedures. We set out to assess the validity of the HKPT priority criteria score (PCS) and map the maximum acceptable waiting times (MAWTs) for patients to levels of urgency. METHODS: Two studies were used to assess convergent and discriminant validity. In study 1, consecutive patients on a waiting list for hip or knee arthroplasty were assessed by orthopedic surgeons from the 4 provinces in Western Canada, using the HKPT and data on patient age, gender, joint site, type of surgery (primary or revision), 2 measures of surgeon-rated patient urgency, and diagnosis. In study 2, 6 patients were videotaped during a consultation interview with the surgeon and were assessed by a group of experts. We measured function with the PCS and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: In study 1, we assessed 394 patients, and in study 2, 19 raters assessed the 6 patients. Correlations between the PCS and other measures of physician-rated urgency were strong, ranging from 0.78 to 0.89. For a subgroup of 60 patients, correlation between the PCS and function as measured with the WOMAC was 0.48, and correlation was greater (0.45-0.56) between items measuring similar constructs (e.g., pain at rest) than those measuring different constructs (0.21-0.40). In study 2, median MAWTs ranged from 4 to 24 weeks for 5 levels of urgency based on PCS percentiles. CONCLUSIONS: Results from this study support the validity of the PCS as a measure of surgeon-rated urgency for hip or knee arthroplasty. Evaluative studies are needed to assess the validity and acceptability of the tools and the establishment of MAWTs in clinical practice.