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ISSN: 2574-0407
ISSN: 2574-0407
Marie D Westby
AbstractBackground: There is worldwide variation in rehabilitation practices after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and no agreement on which interventions will lead to optimal short and long term patient outcomes. As a first step in the development of clinical practice guidelines for post-acute rehabilitation after THA and TKA, we explored experiences and attitudes about rehabilitation practices and outcomes in groups of individuals identified as key stakeholders.
Methods: Separate focus groups and interviews were conducted with patients (THA or TKA within past year) and three health professional groups: allied health professionals (AHPs), orthopaedic surgeons, and other physicians, in Canada and the United States. Pairs of moderators led the focus groups using a standardized discussion guide. Discussions were audiotaped and transcribed verbatim. A content analysis within and across groups identified key themes.
Results: Eleven focus groups and eight interviews took place in six sites. Patients (n = 32) varied in age, stage of recovery, and surgical and rehabilitation experiences. Health professionals (n = 44) represented a range of disciplines, practice settings and years of experience. Six key themes emerged: 1) Let's talk (issues related to patient-health professional and inter- professional communication); 2) Expecting the unexpected (observations about unanticipated recovery experiences); 3) It's attitude that counts (the importance of the patient's positive attitude and participation in recovery); 4) It takes all kinds of support (along the continuum of care); 5) Barriers to recovery (at patient, provider and system levels), and 6) Back to normal (reflecting diversity of expected outcomes). Patients offered different, but overlapping views compared to health professionals regarding rehabilitation practices and outcomes following THA and TKA. Conclusion: Results will inform subsequent phases of guideline development and ensure stakeholders' perspectives shape the priorities, content and scope of the guidelines.
Background
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries are highly successful orthopaedic proce-dures for more than 62,000 Canadians [1] and 773,000 Americans
[2] each year. The growth in number of THAs and TKAs exceeds the aging of our population due in part to both younger and older individuals electing joint
1 Rehabilitation Sciences Research Graduate Program, Faculty of Medicine, University of British Columbia, Vancouver, Canada
Full list of author information is available at the end of the article replacement surgery as a feasible option for their advanced hip and knee osteoarthritis (OA) [3].
Nearly all patients receive post-operative physical ther-apy and/or other rehabilitative services in the hospital, as an outpatient or through home care services [4]. How-ever, the setting, timing, amount and treatment approaches differ widely [5-8]. Despite the cost effective-ness of THA and TKA, in-hospital and rehabilitation costs associated with these surgeries place significant burdens on North American healthcare systems [2,9-11]. Rehabilitation interventions (e.g., physical therapy, occu
pational therapy, nursing care) may enhance surgical out- comes; however, their precise contribution to long-term outcomes such as physical function, mobility, participa-tion in life roles and health-related quality of life (HRQoL) is not clear. A National Institutes of Health (NIH) conference concluded that "...rehabilitation ser-vices are perhaps the most understudied aspect of the peri-operative management of TKA patients" [12]. Disparate views on need for total joint arthroplasty (TJA) surgery, expectations and outcomes of surgery have been reported for physicians and patients [13-15], and between surgeons and other health professionals [16]. Hewlett suggests that patients' assessments may differ from those of health professionals due to the influence of needs, attitudes, priorities, experiences and expectations [17]. It is therefore necessary to explore patient and pro- vider expectations to inform clinical practice guidelines. The Canadian health care system is characterized by universal access and government funded health care for physician and hospital-based services, few for-profit pro-viders, and lower national health care expenditures than in the US [18], with its varied access to public and private providers depending on one's insurance. These differ-ences in turn influence surgical wait times [1], access to and funding for rehabilitation services, and health out-comes [18]; thus the need to incorporate both perspec-tives. The purpose of this study was to move beyond the existing literature and explore patient and health profes-sional experiences with current rehabilitation practices and outcomes following THA and TKA to inform the development of clinical practice guidelines applicable for North America.
Methods Sampling frame
We were interested in perspectives from four stakeholder groups: 1) individuals who had a primary THA or TKA for OA within the past year; 2) allied health professionals (AHPs, e.g., physical therapist (PT), occupational thera-pist (OT), nurse, medical social worker) currently provid-ing THA or TKA rehabilitative care, education or counseling; 3) physicians (e.g., rheumatologist, physia-trist, family practitioner) who provide THA or TKA care; or 4) orthopaedic surgeons currently performing THA or TKA. Patients were excluded if they were less than 19 years of age, could not converse in English; or had under-gone THA or TKA surgery for inflammatory arthritis, acute fracture/trauma or tumour. Spouses were permit-ted to join the patient discussion groups.
Recruitment
We therefore used strategies to accrue a purposive sam-ple across stakeholder group, demographics and level of experience. Notices, inviting interested individuals to contact the local study coordinator, were posted in clin-ics, waiting rooms, seniors' centers and arthritis con-sumer groups' newsletters as applicable to each stakeholder group. E-mail notices were distributed using staff directories for all types of health professionals.
Focus Groups/Interviews
Focus groups are particularly suited to studying diverse perspectives to gain insight into participants' experiences [19,20] and were the primary means of gathering data, where possible. Focus groups encourage contributions from less verbal individuals who feel supported by other group members with shared experiences [21]. However, individual interviews were conducted when participants were unable to attend their group. Both focus groups and interviews have been used previously in studying various aspects of THA and TKA care, patient experiences and expectations [22-27], but we are not aware of studies that examine THA and TKA rehabilitation practices and out-comes from multiple stakeholders' perspectives.
A discussion guide was developed with input from a multi - disciplinary group of clinicians experienced in THA and TKA rehabilitation and researchers experi-enced in focus group methodology. Open-ended ques-tions progressed from general and uncued to more specific questions with accompanying probes [20,28]. The discussion guide was tested twice and revised to improve clarity based on health professional and patient feedback. Key questions and probes [Appendix A] were rephrased for each stakeholder group to ensure relevance to participants [20]. Separate focus groups were con-ducted with each set of stakeholders to avoid a perceived hierarchy among mixed professional and professional-patient participants [29].
A pair of moderators led each focus group using the standardized discussion guide. The four moderators were female PTs with experience in TJA rehabilitation and group process and included the lead author. Prior to the first focus group, moderators were given written and vid-eotaped instructions on focus group methodology, mod-erating tips and use of the data collection forms, and each pair conducted a pilot session to gain skill and confidence in moderating sessions and trouble shoot problems related to audiotaping, timing and logistics. Focus group sessions lasted 90 minutes for health pro- fessionals and 120 minutes for patient groups (allowing for a stretch break). Individual semi-structured inter-views (face-to- face or telephone) of 30- 60 minutes were conducted with participants unable to participate in a focus group; they followed the discussion guide. Sessions were audiotaped and transcribed verbatim for analysis. Participants recorded thoughts on a response form prior to sharing their perspectives with other group members. Forms were collected and together with the moderators' field notes served to enrich transcripts and study rigor [30]. Member checking was incorporated into focus groups and interviews by inviting participant feedback on the moderator's summary of the session [21]. Immedi-ately following each focus group, the moderators met to debrief, identify issues that may influence analysis and suggest possible modifications to the discussion guide [21]. Ethical approval was received from the UBC Behavioral Research Ethics Board and the Vancouver Coastal Health Research Institute for the primary site and as required by institutional policy for each of the other sites. All partici-pants provided informed consent prior to participation, and were offered a small token ($10 gift certificate).
Data analysis
A thematic content analysis occured concurrently with data collection to allow for revision of questions and development of new lines of inquiry [20,21,29,31]. After checking transcripts for accuracy, the two authors inde-pendently read the transcripts and performed line-by-line, open coding [29], and, following the process out-lined in Figure 1, developed sub-themes for 'within group analysis' and subsequently refined these into key themes for 'across group analysis' Disagreements in coding and categorization were discussed and the coding framework refined as necessary using a constant comparison approach [29]. Minority opinions or outliers (negative cases) were identified and discussed Data collection was discontinued when it was agreed that no new ideas or issues were likely to be raised [20,29]. A decision audit trail was maintained throughout the data collection and analysis phases. Once key themes were identified, transcripts were reviewed and represen-tative quotes selected for each theme. Portions of the coding framework and final analysis were shared with an independent, experienced qualitative researcher for peer checking [30].
Results
Eleven focus groups and eight semi-structured interviews were conducted in five Canadian and one US site. Partici-pants included 32 patients and four spouses, 30 AHPs, five physicians and nine surgeons [Tables 1 &2]. Despite efforts to recruit an ethnically diverse sample, patients were primarily Caucasian but included one African American and one Aboriginal person living on reserve. Allied health professional groups included PTs, OTs, nurses, physician assistants, social workers, and a rehabil-itation assistant and fitness professional. Physicians included family practitioners, physiatrists and a rheuma-tologist. Focus groups ranged in size from four to 10 par-ticipants.
Key Themes
Within group analyses for each stakeholder group resulted in the subthemes summarized in Tables 3, 4, 5 and 6. Further comparison using constant comparison across groups uncovered six major themes. Thus, sub-theme labels reflect concepts specific to each group whereas the key themes reflect concepts across all partic-ipants. Quotes are attributed to participants by noting their age, gender and group, e.g., 41, F, FP is a 41 year old, female, family practitioner.
Theme 1: Let's talk
A substantial amount of focus group time was spent dis- cussing communication issues. The greatest energy and strongest group interaction occurred over the issues of inter- professional communication and collaboration across settings and throughout the continuum of care. While participants offered descriptions of both positive and negative patient- provider and inter-provider com-munication, most examples described how poor or lack of communication decreased efficiency, effectiveness and collaboration. "Communication amongst all the people involved is pretty much non- existent. There's no communication between surgeons and family doctors anymore." [41 F, FP] "So we have this parade of people with total hips, for example, coming through as though they're all the same and they're not. And I think there's a real need Poor communication across settings (e.g., from in-patient rehab to family practitioner or private PT) was believed to contribute to inconsistent and poorly coordi-nated services and negatively impact clinical outcomes and patient satisfaction. Centralized information, a com-munication form that stays with the patient, better links between facilities and providers, and practice guidelines were suggestions shared by AHPs and physicians as ways to address this issue. 'Team care' was another approach to enhance communication and was acknowledged as more feasible in inpatient rehabilitation settings where differ-ent healthcare providers were housed under the same roof, shared charting and participated in regular team meetings. Inadequate staffing, part time positions and staff turnover negatively impacted team dynamics and consistencies in care. A lack of a collaborative, multidisci- plinary approach was felt to lead to inefficiencies, dupli-cation of services and patient dissatisfaction.
Theme 2: Expecting the unexpected Patients identified a number of unexpected challenges in the post-operative period for which they felt inadequately prepared: pain intensity and management, sleep disturbances, psychological issues and unrealistic activity expectations.
"Nobody said how much pain and swelling there was going to be." [76 F, TKA]
"I think a lot of surgeons forget you've got to sleep - honest to God, they should have to go through it. The first thing is you'd be offered, you know, adequate pain medication post-operative and then that sleep is the biggest factor that you're faced with." [73 M, TKA and retired health professional]
"I don't know how many people [with TKA] I've had in the last little while that come in and they're stunned that they have pain postoperatively...They're so not prepared for the amount of pain they have." [43 F, PT] "...after surgery I felt like the bull AND the china shop. Like I feel I am potentially the source of my demise and I feel fragile." [57 F, THA] Of equal concern to many patients and health profes-sionals were the issues of who to go to when post-opera-tive pain was not well-managed and inconsistent advice on whether additional analgesics (e.g. narcotics) were appropriate after the initial acute care period. "I don't think anybody tells the patients, so they go home, they'll be getting some T3's or something by their surgeon or surgical RN and sometimes that's enough, but usually it's not enough... and they just don't think to call or they don't know who to call." [41 F, FP] "...the knowledge of pain management from the patient's perspective and their primary
care provider's perspective is very poor." [55 M, SURG] All study participants viewed the pre-o