'Worse than death' and waiting for a joint arthroplasty

Abstract

Aims: The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state 'worse than death' (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes.

Patients and methods: A cross-sectional analysis of 2073 patients undergoing 2073 THAs (mean age 67.4 years (sd 11.6; 14 to 95); mean body mass index (BMI) 28.5 kg/m² (sd 5.7; 15 to 72); 1253 female (60%)) and 2168 patients undergoing 2168 TKAs (mean age 69.3 years (sd 9.6; 22 to 91); BMI 30.8 kg/m² (sd 5.8; 13 to 57); 1244 female (57%)) were recorded. Univariate analysis was used to identify variables associated with an EQ-5D score < 0: age, BMI, sex, deprivation quintile, comorbidities, and joint-specific function measured using the Oxford Hip Score (OHS) or Oxford Knee Score (OKS). Multivariate logistic regression was performed. EQ-5D and OHS/OKS were repeated one year following surgery in 1555 THAs and 1700 TKAs.

Results: Preoperatively, 391 THA patients (19%) and 263 TKA patients (12%) were WTD. Multivariate analysis identified preoperative OHS, deprivation, and chronic obstructive pulmonary disease in THA, and OKS, peripheral arterial disease, and inflammatory arthropathy in TKA as independently associated with WTD status (p < 0.05). One year following arthroplasty EQ-5D scores improved significantly (p < 0.001) and WTD rates reduced to 35 (2%) following THA and 53 (3%) following TKA. Patients who were WTD preoperatively achieved significantly (p < 0.001) worse joint-specific Oxford scores and satisfaction rates one year following joint arthroplasty, compared with those not WTD preoperatively.

Conclusion: In total, 19% of patients awaiting THA and 12% awaiting TKA for degenerative joint disease are in a health state WTD. Although specific comorbidities contribute to this, hip- or knee-specific function, mainly pain, appear key determinants and can be reliably reversed with an arthroplasty. Cite this article: Bone Joint J 2019;101-B:941-950.

Keywords: Health-related quality of life; Hip arthroplasty; Knee arthroplasty.

Fig. 1

Frequency density graph of preoperative EuroQol five-dimension (EQ-5D) index in patients awaiting total hip arthroplasty (THA) and at one year following THA.

Fig. 2

Chart showing Oxford Hip Scores (OHSs) prior to and one year following total hip arthroplasty (THA) in patients with preoperative ‘worse than death’ (WTD) status (EuroQol five-dimension (EQ-5D) < 0) and in those not WTD (EQ-5D > 0). Error bars represent 95% confidence intervals.

Fig. 3

Receiver operating characteristic (ROC) curve for ‘worse than death’ (WTD) status and Oxford Hip Score prior to total hip arthroplasty (THA; area under curve = 0.87). Diagonal segments are produced by ties.

Fig. 4

Frequency density graph of preoperative EuroQol five-dimension (EQ-5D) index in patients awaiting total knee arthroplasty (TKA) and at one year following TKA.

Fig. 5

Oxford Knee Scores (OKSs) prior to and one year following total knee arthroplasty (TKA) in patients with preoperative ‘worse than death’ (WTD) status (EuroQol five-dimension (EQ-5D) < 0) and in those not WTD (EQ-5D > 0). Error bars represent 95% confidence intervals.

Fig. 6

Receiver operating characteristic (ROC) curve for ‘worse than death’ (WTD) status and Oxford Knee Score prior to total knee arthroplasty (TKA; area under curve = 0.75). Diagonal segments are produced by ties.

Fig. 7

The percentage of patients awaiting a) total hip arthroplasty (THA) and b) total knee arthroplasty (TKA) defined as ‘worse than death’ (WTD) by year and the total annual wait for surgery (from referral to surgery in weeks).