Exploring patient acceptability of a short‐stay care pathway in hospital post arthroplasty: A theory‐informed qualitative study

Abstract Introduction Arthroplasty is an effective, yet costly, surgical procedure for end‐stage osteoarthritis. Shorter stays in hospital are being piloted in Australia. In some countries, short stay is established practice, associated with improving perioperative care and enhanced recovery after surgery practices. Exploring the acceptability to patients of a short stay care pathway in hospital postarthroplasty is important for informing health policy, adoption and potential scalability of this model of care. Methods Consecutive patients at one site, at least 3 months post total joint arthroplasty, were invited to participate in theory‐informed semi‐structured qualitative interviews. The Theoretical Framework of Acceptability (TFA) informed development of the interview guide. Interview data were analysed using the Framework Method. Results Eighteen patients were invited. Fifteen consented to be contacted and were interviewed. Short‐stay post arthroplasty was highly acceptable to patients who had the supports necessary to recover safely at home. Key findings were as follows: flexibility of short‐stay care pathway was essential and valued; prior beliefs and expectations informed acceptability; and the absence of out‐of‐pocket expenses had an incentivizing effect, but was not the primary reason for patients choosing this care pathway. Further themes analysed within the TFA constructs highlighted nuances of acceptability relating to this model of care. Conclusions A short stay in hospital post arthroplasty appeared to be acceptable to patients who had experienced this care pathway. Our thematic findings identified aspects of the short‐stay care pathway that enhanced acceptability and some aspects that limited acceptability. These findings can inform refinement of the short‐stay care pathway. Patient or Public Contribution Patients/people with lived experience were not involved in the study design or conduct of this preliminary work; as this short‐stay model of care was recently introduced, only a small group of patients was eligible to participate in this study. This study is the first step towards understanding the experiences of patients about a short‐stay model of care post arthroplasty. The findings will help inform future patient and public involvement in expanding the programme.


| INTRODUCTION
Osteoarthritis is a highly prevalent and costly condition affecting more than 500 million people worldwide and is a leading cause of pain and disability in older adults. 1 Total joint arthroplasty (referred to from herein as arthroplasty) is a common and effective treatment for endstage osteoarthritis, 2 improving both physical function and quality of life. 3 However, costs of arthroplasty are progressively increasing. 4 At present, osteoarthritis-related hospital admissions in Australia cost AUD $1.2billion annually. 3 Contributing to these costs are initial inpatient admissions as well as readmissions due to postoperative complications. 5 To address these high costs, safe and effective methods of reducing inpatient length of stay are being investigated.
Advances in perioperative medicine and improvements in patient outcomes after arthroplasty are facilitating gradual reductions in hospital length of stay. 6 Internationally, length of stay post arthroplasty varies 7 depending on the preferred model of post operative care. In the United States (US), a short stay in hospital or even same-day discharge post arthroplasty is established practice. 8 In contrast, the average length of stay in Australian private hospitals is 4.8 days after total knee replacement (TKR) and 4.9 days after total hip replacement (THR). 9 Standard care after arthroplasty in Australia typically involves acute hospital care, followed by supervized outpatient or inpatient rehabilitation. 10 These traditional models of care have been challenged by a growing evidence base demonstrating noninferiority of home-based programmes for lower-risk patients after arthroplasty. 11 While one US study found that post operative length of hospital stay was the least important consideration for patients contemplating arthroplasty, 12 the preferences and perceptions of short-stay after arthroplasty amongst Australian patients are unknown.
Adoption of healthcare interventions depends in part on their 'acceptability' to intervention recipients. 13 Patients are more likely to engage with an intervention if they consider it to be acceptable. 13 According to the Theoretical Framework of Acceptability (TFA), 'acceptability' is a multifaceted construct defined as 'the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate' (p. 4). 13 The TFA comprises seven constructs 13 (Table 1 presents TFA constructs and definitions). The TFA has been used successfully in other (nonsurgical) contexts to identify components that could be addressed to enhance acceptability, such as nurse-led reviews of inflammatory rheumatological conditions, postnatal exercise and infant feeding practices. [14][15][16] It has also been applied in a small number of surgical contexts such as MCDONALD ET AL. | 2003 maternal-foetal surgery and intravitreal injections for macular degeneration. 17,18 The TFA has not yet been used in acceptability studies relating to arthroplasty or short-stay models of care. Given that a short stay in hospital after arthroplasty was a new model of care in Australia, exploring acceptability to patients was important for informing the potential scalability of this care pathway.

| Study aim
The aim of this study was to explore the acceptability of a short stay in hospital post arthroplasty from the perspective of patients.

| Study setting and design
This cross-sectional, theory-informed qualitative study was conducted between July and October 2021. The study setting was a single site in Melbourne, Australia, which was the first site where this short-stay care pathway was routinely offered in the state of Victoria.
The researchers approached this study through an interpretivist paradigm, paying attention to people's perspectives in context. 19 Ethical approval was obtained on 29 July 2021 from the University of preadmission preparation and information provision; total joint arthroplasty surgery; short stay in hospital; and rehabilitation and recovery at home ( Figure 1). The pathway aimed to incentivize appropriate short length of stay for suitable patients and included other measures such as individualized prosthesis selection.
Short stay in hospital typically involves a planned hospital admission of one night or, in some cases, same-day discharge. The short-stay care pathway is offered only to eligible patients based on thorough clinical assessment by health professionals. In Australia, another component of the pathway is a 'no gap' financial arrangement, whereby the cost of surgery and associated fees (i.e., costs of hospital stay) are set and covered in full by the health insurer. 21 This means that patients have no 'out-of-pocket' expenses for their surgery or hospital stay, contrasting with typical out-of-pocket doctors' fees for arthroplasty of AUD$600 22 (although out-ofpocket fees are known to vary and can be up to AUD$10 000).
We refer to this arrangement of no added out-of-pocket costs as 'no gap'.

| Participant recruitment
Patients who experienced a short stay in hospital after arthroplasty before May 2021 were consecutively identified. At the time of data collection, selecting this date (May 2021) allowed for at least 3 months postsurgical recovery. Patients who were unable to converse in English, or employees of the health insurer (Medibank) or private hospital (Vermont Private Hospital) were not eligible to participate. Eligible patients were contacted by an administrative T A B L E 1 The Theoretical Framework of Acceptability 13 with definitions adapted for the current study and an additional construct proposed by authors

Affective attitude
How an individual feels about a short stay in hospital after arthroplasty.

Burden
The perceived amount of effort that is required to participate in the short-stay care pathway.

Ethicality
The extent to which the short-stay care pathway has good fit with an individual's value system.

Intervention coherence
The extent to which the participant understands the short-stay care pathway and how it works.

Opportunity costs
The extent to which benefits, profits or values must be given to engage in the short-stay care pathway.

Perceived effectiveness
The extent to which the short-stay care pathway is perceived as likely to achieve its purpose.

Self-efficacy
The participant's confidence that they can perform the behaviour(s) required to participate in the short-stay care pathway.

Additional construct
Perceived safety and risk Any factors perceived to affect safety and risk during the short-stay care pathway.
staff member of the surgical consulting rooms who briefly outlined the aim of the study using a script provided by the research team and who obtained agreement to be contacted by the research team.

| Data collection
Semi-structured interviews were conducted using distance modes (seven by telephone, eight by videoconference) to allow for COVIDsafe practice, minimize participant burden and allow recruitment of patients who lived in regional areas. All interviews were conducted by authors C.M. and C.P. (eight and seven interviews, respectively). The interview guide (Supporting Information: Appendix S1) was developed using a systematic process recommended in theory-informed qualitative research 14 and informed by the TFA (explained further in the section on 'Rigor' below). The interview topic guide was designed to explore the seven constructs of the TFA. The research team proposed an additional construct: 'perceived safety and risk' (Table 1).
This additional construct was added because the research team (including orthopaedic surgeons, anaesthetists, allied health clinicians and an implementation scientist) posited that 'perceived safety and risk' may impact on acceptability in a surgical context and may not be sufficiently covered by the existing TFA constructs.
At the start of each interview, the four stages of the short-stay care pathway were described, and a visual prompt was given to participants (Supporting Information: Appendix S1). This process ensured a shared understanding between the interviewer and the interviewee of the complex intervention that was the focus of the interview. This process is recommended in theory-informed qualitative research. 24 On average, interviews lasted 45 min (range: 35-65 min). Interviews were audio-recorded and transcribed verba- tim. An electronic sociodemographic questionnaire was used to collate participant information at the end of the interviews.

| Data analysis
Participants' demographic data were summarized using descriptive statistics. Interview data (audio recordings and transcripts) were analyzed using an inductive, and then a deductive, approach within the Framework Method. 25 This method was chosen due to its flexibility and because the clear, structured steps can support collaboration between multiple researchers throughout analysis. 25 The Framework Method as described by Gale et al. 25

| 2005
A detailed description of the analytical process at each stage is provided in Supporting Information: Appendix S2. NVivo 12 software (QSR International) was used to enhance the organization, management, visualization and reporting of data.

| Rigor
The following steps contributed to rigor in the design and conduct of this study. First, the interview questions were 'back coded' 26

| Section 1: Overarching themes of acceptability
The following themes represent findings across the interview data set and reflect perceived acceptability of the short-stay care pathway. In these cases, depending on their circumstances, participants either remained in hospital for an additional night and then were discharged home, or were discharged to inpatient rehabilitation.

Marie (TKR):
We're all different and in my case, it probably wouldn't have been an idea to go straight home because of the blanking business [referring to postural hypotensive episodes post-surgery] that I was having.
The short-stay care pathway was occasionally modified according to the needs of the individual following discussions with staff.
This flexibility was perceived to influence multiple constructs of acceptability, including how effective they thought it was (perceived effectiveness), how they felt about it (affective attitude) and how much effort was required to participate (burden). Participants' expectations of their recovery from arthroplasty also influenced whether they thought it was acceptable to have a short stay in hospital. An example of this association was where participants described arthroplasty as 'major surgery'. Participants who perceived arthroplasty as major surgery, but expected that they could recover well at home, thought that a short stay in hospital was acceptable. By contrast, participants who expected that major surgery would require inpatient care to effectively recover did not perceive a short stay in hospital as acceptable.

| Prior beliefs and expectations influence acceptability
Rose (TKR): But also apart from everything else, you're just not well enough to come home … you're just not well enough. Crazy idea.
Expectations of the short-stay care pathway were positively influenced by the 'joint school' (preoperative education sessions) and preadmission appointments. These information sessions influenced the acceptability of a short stay for participants who were predisposed to the short-stay pathway. Participants' prior beliefs and expectations of a short stay and recovering at home impacted on many constructs of acceptability, such as perceived effectiveness, safety, affective attitude, ethicality and self-efficacy.

| Incentivizing effect of the 'no gap' arrangement
The 'no gap' component of the short-stay care pathway 'persuades' people to undertake a short stay in hospital. For some people, the financial arrangement was fundamental to accessing the programme and was therefore highly persuasive.

| Opportunity costs
Theme 1: Short-term reduction in participants' independence and activities, which was anticipated during recovery from surgery and therefore did not detract from the acceptability of the care pathway overall. Theme 2: Benefits of home-based recovery such as less travel time (e.g., to outpatient appointments) and sleeping better in their own bed were highlighted by participants who recovered at home.

| Self-efficacy
Theme 1: Adequate support to cope physically and emotionally at home influenced participants' confidence and whether they felt able to and/or did cope at home. Theme 2: Feeling informed and making progress were described by participants who felt informed following consultations with health professionals, which instilled confidence about their surgery and recovery. When participants perceived that they were making 'good' progress after surgery, this further contributed to a sense of self-confidence to manage at home. Knowing the risks and benefits of inpatient versus home-based recovery influenced acceptability of the short-stay care pathway.

| Intervention coherence
Participants who recounted knowledge of the potential risks of staying in hospital (i.e., developing an infection) explained that this was an important factor driving their preference to recover at home. 'Before and after'-outcomes of surgery make it all worthwhile Thomas (TKR): Yes it certainly has. Very, very effective. So it's helped me a lot… Oh, it was sometimes really simple things like walking up to the local cafe, which I couldn't even walk to the cafe at the end (*referring to pre-surgery pain). It was so bad that I had to be driven there. Ryan (TKR): I would want to say, one of the best things I've ever done was having my knee replaced. I've got virtually no pain now, whereas I had a lot constantly all the time.
Home-based care can accelerate recovery Janet (TKR): But you just heal better in your own bed and sleep in your own bed and be in your own environment. Thomas (TKR): I personally think your state of mind, mental stability, so the mental side of things is much better if you're at home than in hospital. I think if you're mentally better, you're going to heal better quicker anyway.

Affective attitude Anxious and trepidatious about unknowns
Paula (TKR): I was very anxious about the operation and I guess, because of recent events, I was more anxious than I usually am and after I had the operation, it was just a huge relief. Barney (TKR): I was a bit worried that I wasn't going to be independent quick enough.

Positive feelings during recovery and individualized care
Helen (TKR): I was happy with the surgeon, happy with the big hospital. … But as far as the nurses go, they were all lovely. And the physio that came home to the house was very nice. And it all went very smoothly. Ben (TKR): I couldn't be happier with the whole experience of it. First and second time. The first time I was surprised that it was such a brilliant experience, which I wasn't expecting. And the recovery was quick, which I wasn't expecting. There's that side of it. Noah (THR): Well, it could potentially make this surgery much more available to people, because in the public system it's very heavily rationed… I think anything that makes these procedures more available has got to be good. Feeling informed and making progress Alan (THR): There's nothing worse than going into the unknown and not knowing what's going to happen, and I think they did it very well out there…So, it was a full education process so that you were pretty confident about what they were doing. Thomas (TKR): Well, I was quietly confident, but after I'd been home for days I was completely confident, so. Because as I say, I thought it all went very well.

Burden
Intervention coherence Variable understanding of the 'short stay' in the pathway Janet (TKR): There's nothing confusing. It's all streamlined… We'd basically talk it through and they'd send through information. We got sent home with packs and information, so much information. And I felt like I could ring anyone if I didn't understand. Barney (TKR): Well, they wanted to bundle me out after 24 h and I protested, but I stayed in there two nights and then I went to [inpatient] rehab [for] 10 days.
Knowing the risks and benefits Thomas (TKR): Plus the other sort of things like the longer you're in hospital, the more likely you are to get an infection, because it's the most dangerous place you can be is the hospital. Adam (TKR): Because as I said to you, I know about hospitals, and I'm old man, and I just didn't want to stay at the hospital and get an infections or anything else.

Perceived safety and risk
Critical timepoints for clinical and safety assessments Sarah (TKR): I had the GP just across the road from me, because a nurse didn't show up, who was supposed to. So I ended up going to my GP, and they took the dressing off my surgery, and checked it out, and redressed it. And yeah, it was after that, then the blood clot developed. Paula (TKR): Well, for me it [going home] was fine, but I think these things or medical procedures or anything medical is very much a one-to-one, a doctor and a patient decision…Yeah, well [they] assessed me as able to, then very probable I'd be capable of going home early and I think his assessment was accurate.
Support at home enhanced safety Janet (TKR): I think it's extremely safe as long as you have… Well, they're not going to discharge you if you're struggling, but if you have someone to help you, yes, definitely. Paula (TKR): I think because the physio was coming in twice a week. Any concerns, I could always to talk to him, they're specialists in the field these physios. If there was anything going pear-shaped, I had confidence in him to be able to recognize it.
Abbreviations: TFA, Theoretical Framework of Acceptability; THR, total hip replacement; TKR, total knee replacement. Outcomes of the surgery itself (i.e., reduced pain, increased mobility) were integral to perceived effectiveness of the short-stay care pathway for participants. This is similar to findings of a study with patients after pilonidal sinus surgery, whereby acceptability was associated with recovery outcomes. 30 In contrast, one TFA-based study with parent participants who underwent maternal-foetal surgery for spina bifida found that the outcomes were not associated with acceptability. 17 In this context, parents felt responsible to try 'anything in their power' and so the high-risk intervention was perceived as acceptable even when the post surgical outcomes were disappointing (p. 910). 17 This suggests that the clinical outcomes of surgery may not always drive acceptability; however, in the context of arthroplasty within a short-stay model of care, post operative outcomes appear to be important for acceptability.

| Implications for practice
Issues related to perceived safety during the early phases of recovery at home were identified and affected acceptability. Some participants identified early signs of postoperative complications soon after discharge (i.e., swelling, wound ooze, increasing pain), which they thought did not receive timely review as per the planned pathway. In most of these cases, participants were resourceful and initiated review with their own general practitioner. These cases indicate that changes in postoperative surveillance and intervention may further increase acceptability.
As these findings also suggest that in surgical contexts perceived safety and risk may impact acceptability, other researchers using the found that before surgery, over 70% of patients had safety concerns and therefore did not think that they would be able to undergo arthroplasty as an outpatient. 33 To address perceived safety concerns, thorough descriptions of 'short-stay' (i.e., expected length of hospital stay, benefits of recovering at home and typical risks associated with longer hospital stays) in preoperative information sessions and checking patients' understanding may enhance acceptability. As

| Strengths and limitations
The strengths of this study include use of the TFA to inform the study design. The use of theory-informed approaches in implementation research is strongly advocated. 34,35 Acceptability is a complex concept and, until recently, was poorly defined; therefore, use of the TFA is proposed to assist with operationalizing this concept and guiding study methods. 13 We report several findings on using the TFA in a surgical context and on the adequacy of the TFA in surgical contexts in a separate publication. 36 Another strength of this study was the initial inductive analysis, which allowed the research team to consider acceptability across the TFA constructs, identify relationships between some constructs and explore factors outside the constructs that might be associated with acceptability.
Although steps were taken to reduce sampling bias (i.e., consecutive sampling), the sample did not include any self-employed participants and included only two casual or part-time employed participants. This may limit the range of perceptions obtained particularly related to the opportunity cost construct as participants in our sample did not appear concerned about having to take time off work during their recovery period. Further, only English-speaking participants were included. Therefore, these findings may not reflect the experiences of patients from culturally and linguistically diverse backgrounds, which warrant further investigation.
Only the perspectives of those who received the intervention were obtained for this study. Implementation success is also proposed to be linked to the perceived acceptability of those delivering the intervention. 13 The perspectives of stakeholders