Patient Expectations and HRQoL After Total Joint Replacement
Patient Expectations and HRQoL After Total Joint Replacement
A total of 1681 patients on waiting lists for TJR who fulfilled the inclusion criteria and were not excluded by the exclusion criteria agreed to participate in the study and completed the baseline questionnaire before surgery. After the intervention, 892 (53.6%) completed the follow-up questionnaire at 12 months. This is the sample included in the study. The mean age was 68.74 years (SD = 9.92), 59.37% were women, 40.92% underwent total hip replacement, 63.6% had not had a previous intervention, the mean BMI was 29.37 (SD = 4.61) and 59.21% had primary education. Baseline SF-12 and WOMAC HRQoL data, as well as a comparison with the data from non-responders, are included in Table 1. Nonresponders had slightly worse scores in the three WOMAC domains and in the MCS SF-12 domain than responders. In expectation items there were baseline statistically significant differences between responders and non-responders. Responders had higher expectations than non-responders.
Patients' preoperative expectations were quite high (Table 1). If we take into account the "high expectations" and "very high expectations", the areas in which patients had the highest expectations of improvement were ability to walk after surgery, and improved pain relief, with 90.6% and 89.7%, respectively. They were followed closely by doing more daily activities (81.1%), improved psychological well-being (79.6%), and improved capacity to interact with others (73.9%).
Regarding associations between each of the expectation questions and change in HRQoL from baseline to 12 months (Table 2), patients' expectations showed, in general, a statistically significant association in all HRQoL domains, so, the higher patients' expectations, the more they improved. Therefore, patients with high or very high pain relief or daily activities expectations improved more in all HRQoL domains except SF-12 MCS domain, than patients with low expectations. With regard to ability to walk, interact with others and psychological wellbeing expectations, patients with very high expectations showed more improvement in all WOMAC domains than patients with low expectations, and patients with high or very high expectations showed more improvement in SF-12 PCS domain than patients with low expectations.
Table 3 shows the results of multivariate general linear models to determine the association of baseline patient expectations jointly with changes in WOMAC and SF-12 domains 12 months after surgery, adjusting for confounding covariables and baseline HRQoL scores. Patients with higher expectations were associated with higher improvements in HRQoL at 12 months. There were two the expectations associated regarding WOMAC pain and function domains: patients with high or very high pain relief expectations improved more than patients with low expectations and patients with very high ability to walk expectations improved more than patients with low or high expectations. Expectations associated with WOMAC stiffness were pain relief. Regarding SF-12 PCS domain patients with very high ability to walk expectations were associated with more improvements than patients with low or high expectations. Finally patients with high or very high pain relief expectations improved more in SF-12 MCS than those with low expectations. The covariables that showed association with change in HRQoL at 12 months were baseline HRQoL scores, joint, BMI, education and previous intervention. Explanatory ability of the models, in the case of change in WOMAC and SF-12 domains at 12 months, were from 35% to 57%, apart from SF-12 PCS (R = 0.24). Multilevel analysis showed that the previous results remained after adjusting for the effect of the participating hospital.
Taking into account that after adjustments, the two expectations which were associated with change in WOMAC domains were those related to pain relief and ability to walk, we compared the MCID% for each WOMAC change score according to expectation categories. Among patients with low pain relief expectations, the patients exceeding the MCID in WOMAC domains after surgery varied from 53.4% to 58.4%, while this range was higher for patients with high or very high expectations, which varied from 75.0% to 79.2%, except for WOMAC stiffness domain which was 62.8% and 69.2% for high and very high expectations, respectively. Regarding ability to walk expectations, the percentage of patients with low expectations exceeding the MCID after surgery ranged from 58.2% to 64.2%, whereas this range was higher for patients with high or very high expectations, which varied from 70.7% to 81.0%, apart from WOMAC stiffness domain with a percentage of 61.1%.
In Table 4 we can observe the unadjusted association of level of expectations with satisfaction 12 months after surgery. In the univariate logistic model expectations related to satisfaction were pain relief, daily activities and ability to walk, but in the multivariate logistic model only daily activities expectations remained significantly associated with satisfaction after surgery. So, we do not show results of the multivariate logistic model because these are the same that appeared in the univariate logistic model. Thus, patients with high or very high daily activities expectations had more likelihood to be satisfied than patients with low expectations. No adjusting covariable was associated with satisfaction at 12 months in the multivariate logistic model. The AUC of the model was 0.57. Multilevel analysis showed that the previous results remained with the adjustment for the effect of the participating hospital.
Results
A total of 1681 patients on waiting lists for TJR who fulfilled the inclusion criteria and were not excluded by the exclusion criteria agreed to participate in the study and completed the baseline questionnaire before surgery. After the intervention, 892 (53.6%) completed the follow-up questionnaire at 12 months. This is the sample included in the study. The mean age was 68.74 years (SD = 9.92), 59.37% were women, 40.92% underwent total hip replacement, 63.6% had not had a previous intervention, the mean BMI was 29.37 (SD = 4.61) and 59.21% had primary education. Baseline SF-12 and WOMAC HRQoL data, as well as a comparison with the data from non-responders, are included in Table 1. Nonresponders had slightly worse scores in the three WOMAC domains and in the MCS SF-12 domain than responders. In expectation items there were baseline statistically significant differences between responders and non-responders. Responders had higher expectations than non-responders.
Patients' preoperative expectations were quite high (Table 1). If we take into account the "high expectations" and "very high expectations", the areas in which patients had the highest expectations of improvement were ability to walk after surgery, and improved pain relief, with 90.6% and 89.7%, respectively. They were followed closely by doing more daily activities (81.1%), improved psychological well-being (79.6%), and improved capacity to interact with others (73.9%).
Patients' Expectations and Change in HRQoL
Regarding associations between each of the expectation questions and change in HRQoL from baseline to 12 months (Table 2), patients' expectations showed, in general, a statistically significant association in all HRQoL domains, so, the higher patients' expectations, the more they improved. Therefore, patients with high or very high pain relief or daily activities expectations improved more in all HRQoL domains except SF-12 MCS domain, than patients with low expectations. With regard to ability to walk, interact with others and psychological wellbeing expectations, patients with very high expectations showed more improvement in all WOMAC domains than patients with low expectations, and patients with high or very high expectations showed more improvement in SF-12 PCS domain than patients with low expectations.
Table 3 shows the results of multivariate general linear models to determine the association of baseline patient expectations jointly with changes in WOMAC and SF-12 domains 12 months after surgery, adjusting for confounding covariables and baseline HRQoL scores. Patients with higher expectations were associated with higher improvements in HRQoL at 12 months. There were two the expectations associated regarding WOMAC pain and function domains: patients with high or very high pain relief expectations improved more than patients with low expectations and patients with very high ability to walk expectations improved more than patients with low or high expectations. Expectations associated with WOMAC stiffness were pain relief. Regarding SF-12 PCS domain patients with very high ability to walk expectations were associated with more improvements than patients with low or high expectations. Finally patients with high or very high pain relief expectations improved more in SF-12 MCS than those with low expectations. The covariables that showed association with change in HRQoL at 12 months were baseline HRQoL scores, joint, BMI, education and previous intervention. Explanatory ability of the models, in the case of change in WOMAC and SF-12 domains at 12 months, were from 35% to 57%, apart from SF-12 PCS (R = 0.24). Multilevel analysis showed that the previous results remained after adjusting for the effect of the participating hospital.
Taking into account that after adjustments, the two expectations which were associated with change in WOMAC domains were those related to pain relief and ability to walk, we compared the MCID% for each WOMAC change score according to expectation categories. Among patients with low pain relief expectations, the patients exceeding the MCID in WOMAC domains after surgery varied from 53.4% to 58.4%, while this range was higher for patients with high or very high expectations, which varied from 75.0% to 79.2%, except for WOMAC stiffness domain which was 62.8% and 69.2% for high and very high expectations, respectively. Regarding ability to walk expectations, the percentage of patients with low expectations exceeding the MCID after surgery ranged from 58.2% to 64.2%, whereas this range was higher for patients with high or very high expectations, which varied from 70.7% to 81.0%, apart from WOMAC stiffness domain with a percentage of 61.1%.
Expectation and Satisfaction
In Table 4 we can observe the unadjusted association of level of expectations with satisfaction 12 months after surgery. In the univariate logistic model expectations related to satisfaction were pain relief, daily activities and ability to walk, but in the multivariate logistic model only daily activities expectations remained significantly associated with satisfaction after surgery. So, we do not show results of the multivariate logistic model because these are the same that appeared in the univariate logistic model. Thus, patients with high or very high daily activities expectations had more likelihood to be satisfied than patients with low expectations. No adjusting covariable was associated with satisfaction at 12 months in the multivariate logistic model. The AUC of the model was 0.57. Multilevel analysis showed that the previous results remained with the adjustment for the effect of the participating hospital.
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