Establishing a hierarchy of total knee arthroplasty patients' goals and its congruity to health professionals' perceptions: a cohort study

To formulate a hierarchy of primary goals of patients prior to total knee arthroplasty (TKA) and evaluate the agreement between patients and health professionals regarding this hierarchy of patient goals.


Introduction
Osteoarthritis (OA) is a chronic condition commonly leading to the consideration of total knee arthroplasty (TKA) at end-stage of disease and when patients no longer respond to conservative management. 1,2The best available evidence for the effectiveness of TKA demonstrated a moderate improvement in function compared to non-operative treatment, though at the expense of significant risk of adverse events. 3It has also been reported that approximately 10%-20% of patients continue to experience pain or functional deficits post-surgery, though no clear criteria for identifying these patients a priori currently exists. 4,5The associated dissatisfaction with these persistent deficits are a significant issue that has continued to warrant further investigation. 4][8] Health professionals play a key role in setting the expectations of patients considering TKA and facilitating informed decisionmaking regarding whether surgery is appropriate. 9Health professionals must be able to elicit what opinions their patients have regarding their goals, such as the priority of these goals and how likely they are to achieve them.This poses a challenge as these must be elucidated and treatment or expectations appropriately adjusted for individual patients.This is often complicated when patients are less able to communicate their views, common in patients presenting with lower health literacy. 10In these circumstances, health professionals may need to act as a surrogate to the decision-making process in an attempt to provide the patient with the best option. 11,12As a result of these unidentified goals and expectations, health professionals may need rely on previous experiences or decisions that may not be applicable to each patient. 13It is therefore valuable to have a set of goals or objectives that are most important to patients for health professionals to focus on when exploring treatment options.
Poor communication between individual health professionals and their patients also threatens the optimal decision-making process. 14ffectively communicating reasons for treatment recommendations between professionals is paramount to the patient's continuity of care and addressing their needs. 15,16However, when health professionals are unable to elicit the same information from patients, conflicting treatments may be suggested.Standardized methods for eliciting pertinent goals of treatment from patients have been suggested, and these approaches would benefit from involved specialities exploring similar concepts. 17This may improve the identification of patients who would benefit most from surgery and ultimately the satisfaction of patients receiving this elective procedure.Therefore, the primary aim of this study was to identify the most important goals of treatment to patients and establish a hierarchy of these goals to inform shared decision-making between patients and health professionals.The secondary aim of this study was to evaluate how closely health professionals involved in the recommendation of surgery thought their patients ranked their main goals of treatment compared to the patient-reported hierarchy of goals.

Design and recruitment
This prospective cohort study was conducted at a multi-surgeon public hospital arthroplasty clinic using a consecutive sample of 110 patients suffering from OA who were within a fortnight of receiving a primary TKA.Patients were recruited from June to September 2019 and were on average 71.8 (SD 9.3) years of age and due to have their surgery on their left (n = 51, 46.4%), right (n = 49, 44.5%) or bilaterally (n = 10, 9.1%).Shared decision-making between patients and their treating team was assessed using The 9-item Shared Decision-Making Questionnaire (SDM-Q-9) scored out of 100 points (where a higher score indicated greater perceived shared decision-making) 18 and catastrophisation of pain was elicited using the Pain Catastrophising Scale (PCS) scored out of 52 points (where a higher score indicated greater pain catastrophisation). 191][22] In this study, patients were interviewed by a single physiotherapist to identify their most important goals regarding their knee in context of the pending knee arthroplasty.Goals were discussed with the patient so that clear goals could be defined, and these were then collaboratively summarized into the patient's own words.Patients were then asked to rate the importance of each goal, their current ability to perform the goal and their expectation that a total knee arthroplasty would help them achieve the goal, scored on a 10-point numerical rating scale.Where a goal referred to an overarching concept in context of a specific task, the overarching goal was only included if the specific task could not be categorized otherwise.Identified goals were categorized into themes by three authors using an inductive thematic approach, in pursuit of saturation of themes raised by patient participants.A hierarchy was then formulated based on the number of unique patients to report a goal within each theme.Where themes had an equal number of patients reporting a response, each patient's highest importance score for responses within the theme was used to calculate a mean score to resolve the position in the hierarchy.If this did not resolve the positioning, the lowest current ability score and then the highest expectation score were used.Where patients provided multiple goals relating to the same theme, the number of overall related responses were counted, but the theme was only included once from unique patients when formulating the hierarchy.
Health professionals from whom patients seek advice regarding the decision to have surgery were invited from public hospitals and private clinics across New South Wales, Australia.These health professionals were asked to anonymously arrange a computer-generated randomized (Fisher-Yates shuffle) list of identified goals into a hierarchy that they believed patients reported as most important to them.Using the positioning health professionals within each specialty placed each patient goal, a hierarchy was established.Health professionals were recruited from October 2019 to June 2020 (n = 94).These included orthopaedic surgeons (n = 49, 52.2%), rheumatologists (n = 16, 17.0%), physiotherapists (n = 16, 17.0%) and general practitioners (n = 13, 13.8%).Experience varied, practicing for an average of 16.9 (SD 11.1) years, and clinicians saw an average of 1.9 (SD 2.3) TKA patients per week (Table 1).
Institutional ethical approval was attained prior to commencement of this study from the Sydney Local Health District Human Research Ethics Committee (Protocol Number X19-0120 & 2019/ ETH08675).This study was conducted in line with the recommendations of the STROBE Initiative (Appendix A). 23

Statistical analysis/power
While the identification of all patient-reported goals towards saturation of themes was of primary focus, a minimum sample size was calculated in pursuit of assessing the achievement of goals by patients post-operatively.Based on previous studies investigating the changes to the DQO in patients undergoing surgery, 21,22 a sample size of 36 was required to achieve 80% power to detect a mean paired difference of 0.211 in total DQO score at 1 year, with an estimated standard deviation of differences of 0.433 and with a significance (α) of 0.05 using a two-sided paired t-test. 24,25endall's Tau (τ b ) correlation was used to determine correlations between hierarchies suggested by groups.Strength of correlation was assessed as weak (τ b < 0.26), moderate (τ b = 0.26-0.49)or strong (τ b > 0.49), where a P-value ≤0.05 was considered statistically significant.

Patient goals and hierarchy
Patients were found to believe they participated in substantial shared decision-making (mean AE SD, 87.5 AE 13.5) and suffered from pain catastrophisation (mean AE SD, 27.6 AE 16.0), particularly concerning the amplification of the secondary effects of their pain (Table 1).A majority of patients identified five goals that they believed were important regarding their knee pain in context of the pending knee arthroplasty (n = 85, 77.3%).However, four patients only identified one (n = 2, 1.8%) or two (n = 2, 1.8%) goals, of which all identified improving mobility with or without the goal of relieving pain.For this study, the only generalized goal patients identified pertained to improving their quality of life.This goal was only represented in the hierarchy if the patient reported either a generalized goal to explicitly improve quality of life or improve an otherwise uncategorisable goal in the hierarchy they identified as impacting their quality of life.Based on these responses from patients, a hierarchy was established (Table 2).Overall, most patients (n = 106, 96.4%) reported improving mobility as being a major goal of treatment, followed by reducing pain in their knee (n = 101, 91.8%), improving daily tasks (n = 89, 80.9%), returning to social and leisure activities (n = 60, 54.5%), and improving their knee range of motion (n = 43, 39.1%).However, the concept of reducing pain in the knee (n = 270) was more commonly repeated by individual patients in related responses, as compared to the concept of improving mobility (n = 260) (Table 2).Despite some themes not being reported as often, when reported, they were described to be equally important to all other stated goals.
Patients reported high expectations for TKA to address all the identified goals (Table 2).The goals with the highest expectation to resolve were reducing pain in the knee (mean AE SD, 9.46 AE 0.98), returning to work (mean AE SD, 9.46 AE 0.93), improving quality Abbreviations: OA, osteoarthritis; PCS helplessness, concern for how much the pain affects overall life (0-24, where a higher score indicates greater concern); PCS magnification, amplification of the secondary effects of pain (0-12, where a higher score indicates greater amplification); PCS rumination, thinking about how much the pain hurts (0-16, where a high score indicates greater pain focus); PCS, pain catastrophising scale (0-52, where a higher score indicates greater pain catastrophising); SD, standard deviation; SDM-Q-9, shared decision-making 9 item score (0 to 100, where a higher score indicates greater perceived shared decision-making); TKA, total knee arthroplasty.Note: Overall related responses (n = the number of times the theme was reported in multiple goals by unique patients); Importance of goal to patient (where 0 = not important at all, 10 = the most important); Pre-operative ability of patient to perform the goal (where 0 = not able to perform goal at all, 10 = completely able to perform goal); Patient expectation for TKA to resolve issues (0 = does not expect to resolve; 10 = completely expects to resolve).
of life (mean AE SD, 9.29 AE 0.97) and improving mobility (mean AE SD, 9.25 AE 1.22).The goals of improving knee range of motion (mean AE SD, 8.88 AE 1.24) and reducing "non-knee" related medical issues such as back or hip pain (mean AE SD, 8.60 AE 1.34) were found to be highly expected to resolve, though less so than other identified goals.

Health professional hierarchy
When comparing the established patient goals hierarchy to what health professionals thought was most important to patients, general similarities were found (Tables 3 and 4).As a group, health professionals were able to identify four of the top five goals of patients, identifying mobility as less important.The most common major divergences in rankings between patients and health professionals as a group, were regarding improving mobility and improving quality of life.This divergence from patient ranking was found in a consistent position across each health professional group.Generally, a moderate to strong correlation was identified between patients and health professionals, and strong correlation between health professionals (Table 4).Orthopaedic surgeons were found to identify what patients wanted to achieve most similarly to patients compared to other health professionals in the surveyed population, with a strong correlation between groups (τ b = 0.556, P = 0.03) identified.The only major difference between patients and surgeons was regarding the goals of improving mobility and improving quality of life, as noted above.Comparing the hierarchy between surgeons and other health professionals, the largest divergence was found with rheumatologists.
Regarding the other surveyed health professionals, responses varied when compared to patients and other health professions.Though rheumatologists were found to have a statistically significant correlation with patients (τ b = 0.511, P = 0.04), divergences were found in half of the identified goals.Compared to other health professionals, rheumatologists were found to have the greatest divergence to physiotherapists (τ b = 0.600, P = 0.02).Physiotherapists were found to rank the identified goals similarly to patients (τ b = 0.378, P = 0.13).When compared to other health  Hierarchy of total knee arthroplasty patients' goals and its congruity to health professionals' perceptions professionals, physiotherapist rankings differed most to rheumatologists (τ b = 0.600, P = 0.02) and general practitioners (τ b = 0.629, P = 0.01).Notably, physiotherapists were the only group to rank improving daily tasks in the bottom half of the patient goals hierarchy.General practitioners were also found to rank the identified goals similarly to patients (τ b = 0.449, P = 0.07), with the only other main difference being their belief that patients wanted to address the risk of falling more often.This group was found to rank the goals similarly to orthopaedic surgeons (τ b = 0.764, P ≤ 0.01).However, similarly to the comparison to patients, this group reported a belief that patients wanted to address falls prevention more often than all other health professionals.

Statement of principal findings
This study determined and ranked the goals of patients prior to undergoing TKA and compared this to health professionals' rankings of the same patient goals.Patients overwhelmingly sought to address the goals of improving mobility, reducing pain in the knee, and improving daily tasks more than other goals, and strongly believed that TKA would achieve these goals.When comparing the hierarchy determined by patients to what health professionals thought patients wanted to be addressed most often, overall similarities were found between groups of health professionals and between health professionals and patients.However, health professionals placed more emphasis on improving quality of life and less emphasis on mobility, compared to patients.

Meaning of the study
The results of this study primarily provide a hierarchy of goals for patients considering TKA to be employed by health professionals when structuring their assessments.Patients were found to consistently refer to improving pain and mobility as their key goal, supporting the findings of previous studies. 6,8,26Patient-centred care is paramount in this population, where individual patient interpretations of the impact of their arthritis, goals of treatment and expectations affect their ultimate ability to achieve a successful outcome. 27,28Setting of unrealistic goals has particularly been associated with poorer outcomes and therefore taking a more patientcentred approach has been advocated. 29,30As with previous studies, patients in the current study reported high expectations of surgery to address their goals. 8Though, the current study provides evidence that health professionals are generally able to identify what their patients most often seek to achieve, potentially facilitating patient perceived better shared decision-making.However, the findings of this study also suggest that health professionals may benefit from more closely elucidating the importance patients place on specific goals, when deciding whether to offer knee arthroplasty.Health professional decision-making is commonly affected by clinical experiences, familiarity with high quality literature and ability to extract the goals of individual patients. 31This study identified some discordances between patients and health professionals, and multiple discrepancies between individual health professional specialties.Of note was the smaller number of patients generically identifying improving their quality of life as a goal.Rather, these patients commonly associated their quality of life with a specific goal that could be categorized within the established hierarchy.This finding further supports the idea that patients may benefit from their specific goals being elucidated.Considering health professionals commonly act as educators and in some cases surrogates for patient's decision-making, it is important for health professionals as a group to reflect on their own biases, aim to elicit consistent information from patients and communicate effectively between each other. 11,12,14,318]26 However, this study goes further by establishing a hierarchy of patient goals and compares these to hierarchies provided by health professionals involved in the recommendation of this surgery.The study was adequately powered to evaluate the stated aims and patients were recruited until saturation of themes was achieved.Additionally, the recruited sample was of comparable size to a similar study by Lange et al. 26 The main strength of this study was the prospective nature in which patients were individually interviewed to accurately elicit the key goals of treatment and contextualize these responses in term of their importance and expectations of fulfilment.Previous studies have commonly focussed on questionnaires requesting patients to respond to pre-selected goals. 7,8,32These studies provide strong evidence concerning the rate at which expectations are met, however may not fully consider the complexities of a patient's situation or objectives in the same way as a focused interview.A further strength of this study was the sampling of health professionals involved in the recommendation of knee arthroplasty from a variety of settings.Decision-making is commonly a function of the surrounding healthcare system and sampling from different sources may strengthen confidence that these findings are representative. 33espite these strengths, this study was not without limitations.The choice to only include responses from patients suffering from OA means the results of this study are constrained to this population.Though according to national arthroplasty registry data, most patients receiving TKA present with this as their primary diagnosis. 34A further potential limitation is how themes were constructed and finalized.The qualitative nature of the data lends itself to measurement bias and variation in interpretation due to its openness.However, elicited themes and any divisions of these were confirmed by three authors.Patients and health professionals may also have their own interpretations of what goals mean, especially when considering their unique experiences.This is an unavoidable limitation when evaluating perceptions regarding goals of treatment due to the subjectivity of these concepts.A final potential limitation of this study was accepting responses to the health professional survey from those who assess any patients suffering from OA. Included health professionals may see patients at different stages in their journey, potentially altering their perception of patient goals.Whilst health professionals were instructed to respond from the perspective of patients who were considering surgery, there was no practicable way to enforce this.

Unanswered questions and future research
Given the differing opinions between patients and health professionals regarding mobility and quality of life, the results of this study support further evaluation into the differences in how each are formulated and interpreted.Understanding what factors influence their formulation, the phrasing that is used by each group to convey these concepts and how these can be best communicated between stakeholders has the potential to align expectations, contributing to higher overall satisfaction with the decision-making process.
Evidence from this study also supports the investigation of the types of patient-reported outcomes that health professionals should employ to evaluate the recovery of patients following surgery.With the increasing call for standardization of outcome measures from governing bodies 35 and international experts 36 amid the varied options currently in use, 37 it is important that selected measures provide information reflecting key goals of patients.Further, the language used in these measures should possess the utility to be easily interpretable by patients, whilst also providing health professionals with functionally centric information on their quality of life.
Engaging patients in their own healthcare such that it reflects the goals of their unique presentation is key to ensuring appropriate treatment is recommended. 38It is therefore crucial that patients are involved in a well-defined informed decision-making process centred around tailored education, for example with the use of a patient decision-aid. 39Investigation of a structured education process incorporating the key goals of patients would assist patients and health professionals to participate in a balanced discussion, thereby reducing decisional conflict and consequent dissatisfaction. 12,38

Conclusion
This study established a hierarchy of the goals most important to patients, identifying key goals as improving mobility, reducing pain, and improving daily tasks.Health professionals involved in the recommendation of knee arthroplasty were generally found to be able to identify what patients wanted to achieve most often.However, health professionals ranked quality of life higher, and mobility lower than patients.Incongruity was also found between health professionals, potentially indicating miscommunication or interpretation of information during patient assessments.Future studies should further evaluate these incongruities and continue to facilitate the establishment of an optimal informed decision-making pathway for knee arthroplasty.

Table 1
Participant demographics

Table 2
Hierarchy of pre-operative patient goals

Table 3
Similarity of patient goals hierarchy to perception of health professionals Note: Decreasing shade of grey = decreasing importance to patient.† Moderately similar compared to patients (2 levels different to patient rating).‡ Dissimilar compared to patients (>2 levels different to patient rating).

Table 4
Correlation of patient goals hierarchy to perception of health professionals Note: Correlation using Kendall's Tau: *P ≤ 0.05; **P ≤ 0.01.© 2023 The Authors.ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.