Supporting patients to prepare for total knee replacement: Evidence-, theory- and person-based development of a 'Virtual Knee School' digital intervention

Abstract

Introduction: Digital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.

Objective: To develop a pre-operative TKR education and prehabilitation digital intervention, the 'Virtual Knee School' (VKS).

Methods: The VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).

Results: Most participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend: 1. Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats. 2. Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.

Conclusions: Integrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.

Patient or public contribution: Patient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

Keywords: digital intervention; intervention development; mixed methods; pre-operative education; prehabilitation; total knee replacement.

Figure 1

Project flowchart. Flowchart showing the design and objective of each project phase, and how the phases link to each other and future work. Arrows at the bottom of the flow chart demonstrate that Patient and Public Involvement (PPI) was central throughout the project, and PPI is anticipated to be central during any future related work. Pre‐op, pre‐operative; TKR, total knee replacement; VKS, Virtual Knee School.

Figure 2

Virtual Knee School (VKS) logic model. Logic model of the VKS, including the problems it seeks to address, its main objectives, its key features and intervention processes, its proposed causal mechanisms, the intended patient outcomes and contextual moderators. To avoid overcrowding and ensure legibility, relationships between factors in different columns of the logic model are not shown. Postop, post‐operative; pre‐op, pre‐operative; psych, psychological; TKR, total knee replacement.

Figure 3

Virtual Knee School (VKS) prototype information architecture summary. Summary of the VKS prototype information architecture, showing the five website sections and three page levels. ^a The main section also included the following pages accessible via the header, footer or meganav (expandable menu): Help; Accessibility statement; Privacy and cookies policy; Other helpful websites; Contact us. ^b Users were tunnelled to the introductory section menu on their first login but not subsequent logins.

Figure 4

Meta‐inferences schematic diagram. Summary of the meta‐inferences generated by integrating the findings of all the project phases. The three principles underpinning each meta‐inference, and the intersection between the two meta‐inferences, are included. Pre‐op, pre‐operative; TKR, total knee replacement.