Challenges in outcome measurement: discrepancies between patient and provider definitions of success

Abstract

Some orthopaedic procedures, including TKA, enjoy high survivorship but leave many patients dissatisfied because of residual pain and functional limitations. An important cause of patient dissatisfaction is unfulfilled preoperative expectations. This arises, in part, from differences between provider and patient in their definition of a successful outcome. WHERE ARE WE NOW?: Patients generally are less satisfied with their outcomes than surgeons. While patients are initially concerned with symptom relief, their long-term expectations include return of symptom-free function, especially in terms of activities that are personally important. While surgeons share their patients' desire to achieve their goals, they are aware this will not always occur. Conversely, patients do not always realize some of their expectations cannot be met by current orthopaedic procedures, and this gap in understanding is an important source of discrepancies in expectations and patient dissatisfaction. WHERE DO WE NEED TO GO?: An essential prerequisite for mutual understanding is information that is accurate, objective, and relevant to the patient's condition and lifestyle. This critical information must also be understandable within the educational and cultural background of each patient to enable informed participation in a shared decision making process. Once this is achieved, it will become easier to formulate similar expectations regarding the likely level of function and symptom relief and the risk of adverse events, including persistent pain, complications, and revision surgery. HOW DO WE GET THERE?: Predictive models of patient outcomes, based on objective data, are needed to inform decision making on the individual level. This can be achieved once comprehensive data become available capturing the lifestyles of patients of diverse ages and backgrounds, including data documenting the frequency and intensity of participation in sporting and recreational activities. There is also a need for greater attention to the process of informing patients of the outcome of orthopaedic procedures, not simply for gaining more meaningful consent, but so that patients and providers may achieve greater alignment of expectations and increased acceptance of both the benefits and limitations of alternative treatments.

Fig. 1

This histogram of data derived from the validation trials of the New Knee Society Score depicts the distribution of satisfaction scores at a minimum of 1 year post-TKA (maximum score = 100 points). The range of scores is approximately the same postoperatively as preoperatively, with an average improvement of more than 60 points. Preop = preoperative; postop = postoperative.

Fig. 2

Data derived from the validation trials of the New Knee Society Score show the correlation between values of the New Knee Society satisfaction score and pain score (sum of pain with walking and pain on stairs and inclines). All patients were enrolled at a minimum of 1 year post-TKA. Increasing levels of knee pain with activity are reflected in a larger value of the pain score.

Fig. 3

Results of a preoperative survey of 132 patients and 16 joint surgeons concerning expected outcomes after THA are shown. Differences in the average responses of surgeons and patients are plotted for each item, with corresponding 95% CIs. Reprinted from Jourdan C, Poiraudeau S, Descamps S, Nizard R, Hamadouche M, Anract P, Boisgard S, Galvin M, Ravaud P. Comparison of patient and surgeon expectations of total hip arthroplasty. Plos One. 2012;7:e30195–e30195.