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Patient Dissatisfaction After Primary Total Joint Arthroplasty: The Patient Perspective
Accepted Manuscript Patient Dissatisfaction after Primary Total Joint Arthroplasty: The Patient Perspective Mohamad J. Halawi, MD, Walter Jongbloed, BS, Samuel Baron, BS, Lawrence Savoy, BS, Vincent J. Williams, MD, Mark P. Cote, DPT PII:
S0883-5403(19)30120-2
DOI:
https://doi.org/10.1016/j.arth.2019.01.075
Reference:
YARTH 57055
To appear in:
The Journal of Arthroplasty
Received Date: 13 January 2019 Revised Date:
30 January 2019
Accepted Date: 31 January 2019
Please cite this article as: Halawi MJ, Jongbloed W, Baron S, Savoy L, Williams VJ, Cote MP, Patient Dissatisfaction after Primary Total Joint Arthroplasty: The Patient Perspective, The Journal of Arthroplasty (2019), doi: https://doi.org/10.1016/j.arth.2019.01.075. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Patient Dissatisfaction after Primary Total Joint Arthroplasty:
Mohamad J. Halawi, MD1 Walter Jongbloed, BS2 Samuel Baron, BS2
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Lawrence Savoy, BS1
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The Patient Perspective
Vincent J. Williams, MD1
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Mark P. Cote, DPT1
1. Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
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2. University of Connecticut School of Medicine, Farmington, CT
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Corresponding Author: Mohamad J. Halawi, MD Department of Orthopaedic Surgery University of Connecticut Health Center 263 Farmington Ave Farmington, CT 06030 Phone: 860-679-3520
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Patient Dissatisfaction after Primary Total Joint Arthroplasty: The Patient Perspective
2 ABSTRACT
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Background: Despite improvements in surgical technique and implant longevity, some patients
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continue to report dissatisfaction following total joint arthroplasty (TJA). As patient satisfaction
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is increasingly used as a quality metric, the objective of this study was to gain better
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understanding of satisfaction with TJA from the patient perspective.
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Methods: 551 primary total hip and knee arthroplasties (THA and TKA) with a minimum of 1-
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year follow-up and were responsive to a satisfaction survey were analyzed. The incidence,
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predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate
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and multivariate logistic regression analyses were performed.
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Results: Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most
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significant predictor of dissatisfaction (p=0.037). The most common reasons for dissatisfaction
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following THA were persistent pain (N=14/34, 41%), functional limitation (N=12/34, 35%),
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surgical complication/reoperation (N=4/34, 12%), staff or quality of care issues (N=2/34, 6%),
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and slow recovery (N=2/34, 6%). The most common reasons for dissatisfaction following TKA
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were persistent pain (N=19/46, 41%), functional limitation (N=12/46, 26%), surgical
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complication/reoperation (N=8/46, 17%), staff or quality of care issues (N=5/46, 11%), and
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unmet expectations (N=2/46, 4%).
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Conclusion: While persistent pain and functional limitation are the two leading reasons for
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dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of
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the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical
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outcome and should be interpreted with caution. Potential for incomplete pain relief or full
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functional recovery should be discussed during preoperative counseling. Empathic care is also
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important and should be encouraged to enhance the overall patient experience.
26 Keywords:
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Arthroplasty, hip; knee; patient satisfaction; patient perspective; risk factors.
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29 Introduction
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Patient satisfaction is increasingly gaining significance as quality of care takes central stage in
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today’s healthcare environment. Among patients undergoing total joint arthroplasty (TJA),
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patient satisfaction rates as measured by questionnaires and interviews have ranged from 80% to
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93% [1-5]. While patient satisfaction is arguably the most important outcome, satisfaction is a
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curious term that may represent either an evaluation of the endpoint of care or the process by
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which care is delivered [6]. Some argue that patient satisfaction is more a measure of the latter,
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and therefore, the concept of patient satisfaction as a “customer service” metric should be
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assessed separately from surgical quality and safety metrics [7].
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Previous studies have explored several predictors of patient satisfaction after TJA although the
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vast majority of those studies were primarily focused on total knee arthroplasty [8-13]. Among
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the identified factors were age, sex, race, patient’s personality, comorbidities, severity of
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arthropathy, preoperative diagnosis (e.g., rheumatoid arthritis), mental disorders (e.g.,
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depression/anxiety), preoperative pain at rest, lower preoperative quality of life, and
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postoperative complications requiring readmission [1, 8-10, 12]. Another cause of dissatisfaction
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that has garnered increased attention is failure to meet preoperative expectations [2, 14]. To date,
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no studies have attempted to explore patient satisfaction subjectively from the patient
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perspective, which may provide more insights into this quality metric. If patient satisfaction is to
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factor into evaluation and reimbursement, providers must fully understand this metric.
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The purpose of this study was to gain better understanding of why some patients are not satisfied
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with TJA by directly inquiring the reasons from them. The research questions are: 1) What are
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the satisfaction rates in patients undergoing primary TJA with a minimum of 1-year follow-up?
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What baseline characteristics exist between patients who are satisfied or not satisfied? What are
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the perspectives of patients who are not satisfied? Is patient satisfaction an evaluation of the
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endpoint of care or the process by which care is delivered?
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57 Methods
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Our IRB-approved prospectively collected institutional joint database was retrospectively
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reviewed for all patients who underwent primary THA and TKA with a minimum of one-year
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follow-up. The database was established in 2012 and includes primary and revision cases
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performed by fellowship trained surgeons. Between 2012 and 2017, five surgeons contributed
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their cases to the registry. Our institution is a public academic center. Patient inclusion in the
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database is voluntary and requires consent and willingness to participate in regular surveys. Non-
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elective, tumor-related, and simultaneous bilateral procedures were excluded. In addition, to
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avoid potential confounding effects, patients undergoing a second arthroplasty in another joint
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(hip or knee) within 12 months were excluded. 780 eligible patients were identified. Those
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patients were then contacted via telephone to inquire about their satisfaction with surgery. 477
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patients (61%) who underwent 551 procedures were responsive and included in the analysis.
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Patient satisfaction was assessed by a medical student who received prior training and was
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provided a standardized script to follow when contacting patients via telephone. Patients were
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specifically asked “Are you satisfied with your total hip or knee replacement?” If any indicated
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that they were not satisfied, they were then asked “Mr./Ms. ___, please help me understand why
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you are not satisfied.”
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Preoperative information collected were age, sex, body mass index (BMI), insurance type
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(Medicaid, Medicare, commercial, and worker’s compensation), American Society of
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Anesthesiologist physical classification (ASA), marital status (married/living with a significant
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other vs. living alone/without a significant other), educational attainment (primary/secondary
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school vs. college/university), race (White, Black, Hispanic, or other), smoking status,
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(never/former vs. active), history of clinical diagnosis of depression, disease-specific health
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status (as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index,
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WOMAC), mental health wellbeing (as assessed by the Short Form-12 mental component
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summary, SF-12 MCS), and physical health wellbeing (as assessed by the Short Form-12
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physical component summary, SF-12 PCS). Two cohorts were analyzed: 1) those who were
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satisfied and 2) those who were not satisfied. The primary outcomes of the study were the
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incidence, predictive factors, and subjective reasoning for dissatisfaction. Patient responses were
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carefully read and used to construct a category system, thereby allowing us to systematically
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categorize the qualitative data. Each reason for dissatisfaction was assigned one point. Responses
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in each category had to be clearly and unequivocally related. Patients who indicated multiple
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reasons for dissatisfaction were assigned a point for each reason. The top five categories were
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reported. There were no significant changes in surgical technique or anesthesia during the time
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period study with the exception of multimodal analgesia, which was implemented in 2016.
94 Descriptive statistics including mean and standard deviation for clinical outcome scores
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(WOMAC, SF-12, etc.), age, and BMI, median and range for ASA class, and frequency and
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proportion for sex, education, martial status, race, smoking status, depression, and insurance type
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were calculated to characterize the study groups. Continuous data was examined graphically and
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appeared to follow a normal distribution. Preoperative differences between the satisfied and
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dissatisfaction groups were examined with the independent t test or Mann Whitney test (for ASA
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class) for continuous variables and the chi-square or Fisher’s exact test for categorical variables.
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The difference in the proportion of patients who were dissatisfied before and after the time
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addition of multimodal analgesia was compared to account for this variable. A mixed effects
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logistic regression model was constructed to examine the impact of baseline differences on the
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study outcome. Univariate analysis was performed to identify variables associated with
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satisfaction. Those variables with a p value less than or equal to 0.1 or those known to be
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associated with clinical outcome (ASA score) were included in a multivariable regression model.
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Adjusted odds ratios are presented with corresponding 95% confidence intervals (95% CI).
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Statistical significance was set at p<0.05. All analysis was performed with Stata 15 software
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(StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC).
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Results
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551 procedures were analyzed (275 THAs and 276 TKAs). Patient satisfaction rates following
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THA and TKA were 89% and 88% respectively at a mean follow-up of 41.0 months (range 12–
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72 months). There were no differences in age (p = 0.395), sex (p = 0.558), ASA class (p =
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0.285), BMI (p = 0.844), educational attainment (p = 0.054), marital status (p = 0.496), SF-12
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PCS (p = 0.105), or SF-12 MCS (p = 0.078) between those who were satisfied or not (487 vs.
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64). However, patients who were not satisfied were more likely to be of Hispanic race (p=0.002)
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and have poorer WOMAC score (p=0.004). There was no difference in dissatisfaction before or
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after the implementation of multimodal analgesia (12% vs. 11%, p=0.760). Table 1 summaries
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the baseline characteristics of the study cohorts.
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Table 2 summarizes the results of the multivariate regression analysis. In this analysis, only
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Hispanic race remained a significant predictor of dissatisfaction relative to White race (OR
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4.143, 95% CI 1.122–15.304, p = 0.033). When African American race was used as a reference,
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Hispanic race remained more predictive of dissatisfaction although this did not reach statistical
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significance (OR 3.376, 95% CI 0.754–15.114, p = 0.112).
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All dissatisfied patients provided their perspectives on why they were not satisfied with surgery.
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The most common reasons for dissatisfaction following THA were persistent pain (N=14/34,
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41%), functional limitation (N=12/34, 35%), surgical complication/reoperation (N=4/34, 12%),
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staff or quality of care issues (N=2/34, 6%), and slow recovery (N=2/34, 6%). The most common
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reasons for dissatisfaction following TKA were persistent pain (N=19/46, 41%), functional
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limitation (N=12/46, 26%), surgical complication/reoperation (N=8/46, 17%), staff or quality of
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care issues (N=5/46, 11%), and unmet expectations (N=2/46, 4%). Tables 3 and 4 summarize the
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top 5 reasons for dissatisfaction following THA and TKA respectively.
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Discussion
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In this study, we sought to gain better understanding of predictive factors and subjective reasons
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for patient dissatisfaction following TJA. 89% and 88% of patients were satisfied with their THA
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and TKA respectively. Hispanic race was the most significant predictor of patient dissatisfaction.
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To date, there is limited information about the effect of race on TJA outcomes; and to our
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knowledge, this is the first study to report on the effect of Hispanic race. In a systematic review
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of patients undergoing TKA, Goodman et al [15] found that only 7 of 5127 studies screened
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(0.001%) included race in their analysis. In those studies, US blacks were found to have lower
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satisfaction rates at 6–24 months postoperatively. In another systematic review by Bass et al
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[16], US blacks were at higher risk for revision TKA than whites. In this study, while Black race
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was also associated with higher rates of dissatisfaction, Hispanic race was found to be most
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predictive of dissatisfaction.
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Persistent pain was the most common cause for dissatisfaction (41% for both THAs and TKAs).
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Persistent pain has been frequently cited as a major cause of patient dissatisfaction although an
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adequate medical explanation for this complaint is often lacking [1, 11, 17]. Vasileios et al [18]
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retrospectively reviewed 272 patients who underwent primary TKA at a minimum follow-up of 1
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year. 39% of patients reported persistent pain ranging from 3–5 out of 10. Length of surgical
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procedure, patellofemoral joint overstuffing, diabetes mellitus, and preoperative flexion
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contracture were identified as risk factors. In another retrospective review of 1030 patients
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undergoing primary TJA at a minimum of 1 year follow-up, Liu et al [19] found the rates of
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persistent pain were 38% and 53% for THA and TKA respectively. The authors identified female
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sex, younger age, previous hip or knee surgery, presence of pain in other areas of the body, and
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inadequate postoperative pain control to be predictive of incomplete pain relief.
162 As persistent pain and functional limitation rank among the top two reasons for dissatisfaction in
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this study, a synergistic effect between these factors should be considered. For example, pain-
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related fear of movement has been shown to be predictive of postoperative functional difficulties
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[20]. Other predictors of activity limitation after primary TJA are BMI > 35, depression, age >
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70 years, female sex, and ipsilateral lower extremity joint involvement [21, 22].
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A small proportion of patients reported dissatisfaction with the care they received in the hospital
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or immediate postoperative period following TJA. This is an interesting observation and
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indicates that patient satisfaction is not just a reflection of the surgical procedure itself. Despite
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assessing patient satisfaction at least one year from surgery, dissatisfaction with immediate
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surgical care lingered in 6% and 11% in patients undergoing THA and TKA respectively.
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Responses included dissatisfaction with members of the health care team, including surgeons,
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nurses, and physical therapists. The degree to which patient satisfaction with the care received
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from the health care team correlates with outcomes is a subject of ongoing research. Hamilton et
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al [2] reviewed a prospective cohort of 4709 patients undergoing primary TJA and found that
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satisfaction with the hospital experience was a major predictor of the patient’s overall
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satisfaction after TJA. More recently, in a retrospective review of 692 patients who underwent
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primary THA, Mistry et al [23] found that patients’ perception of their treating nurses and
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orthopaedic surgeons significantly correlated with how they rated their hospital experience.
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Although our respondents did not report unmet expectations as a major reason for dissatisfaction,
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this outcome is likely a component of other reasons for dissatisfaction. In other words, patients
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who report persistent pain or functional limitation likely also have unmet expectations.
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Substantial research has emphasized the importance of meeting expectations in patient
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satisfaction [1, 14, 24]. As patient expectation is a modifiable factor, initiatives to better inform
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those expectations may contribute to higher rates of satisfaction.
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This study has several strengths and limitations. Research has shown that although large
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functional improvements are achieved within the first 3 months post surgery, continued
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improvement can be seen up to a year [27]. Assessing satisfaction at or greater than the one-year
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mark is therefore a major strength of this study. In addition, we used open ended questions to
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allow patients to freely explain the reasoning behind their dissatisfaction. One potential
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shortcoming, however, is that data collection relied upon patient recall and did not provide a
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comprehensive symptomatic history for any one patient. However, many patients reported
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reasons for dissatisfaction that were ongoing, such as persistent pain and functional limitation.
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Another limitation is only 61% of eligible patients were responsive to the satisfaction survey.
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In conclusion, patient satisfaction following TJA proved to be a complex outcome metric to
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assess. Patient satisfaction is influenced by non-modifiable characteristics (e.g., race). It is also a
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reflection of both the response to the surgical procedure (persistent pain and/or functional
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limitation) and quality of “service” rendered by members of the care team (surgeons, nurses, and
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physical therapists). Patient satisfaction is not solely a reflection of surgical outcome and should
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be interpreted with caution. The potential for incomplete pain relief and full functional recovery
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should be discussed during preoperative counseling. Further studies should be directed to
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correlate the responsiveness of existing patient reported outcome measures (PROMs) to patient
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satisfaction. As patient satisfaction plays a greater role in reimbursement, selecting appropriate
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PROMs that allow detection of poor responders, especially in pain and function domains, may
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allow early intervention to improve satisfaction with surgery. Last but not least, empathic care is
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important and should be encouraged to enhance the overall patient experience.
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Table 1. Baseline characteristics of the study cohorts.
Age (years)
Not Satisfied
487
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60.9 (± 11.7)
59.6 (± 11.1)
Sex Female
255 (52%)
Male
232 (48%)
P value
0.395
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Satisfied
36 (56%)
0.558
2 (1-4)
American Society of Anesthesiologists Classification System 2
Education
2 (1-3)
0.285
31.0 (± 5.0)
0.844
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31.1 (± 5.3)
Body Mass Index (kg/m )
28 (44%)
214 (46%)
36 (59%)
College/University
252 (54%)
25 (42%)
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Primary/Secondary School
Marital Status
0.054
Married/Living with a Significant Other
213 (45%)
31(50%)
Living Alone/Without a Significant Other
256 (55%)
31 (50%)
White
371 (76%)
39 (61%)
Black/African American
72 (15%)
10 (16%)
Hispanic/Latino
28 (6%)
12 (19%)
16 (3%)
3 (5%)
14 (22%)
110 (23%)
0.898
Never/Former Active
402 (87%) 62 (13%)
48 (77%) 14 (23%)
0.052
Medicaid
124 (30%)
24 (41%)
Medicare
164 (40%)
21 (36%)
Commercial
118 (29%)
13 (22%)
6 (1%)
0
Western Ontario and McMaster Universities Osteoarthritis Index
57 (± 21)
65 (± 21)
0.004
Short Form-12 Physical Component Summary
28 (± 9)
26 (± 9)
0.105
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Depression Smoking Status
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Other
Worker’s Compensation
0.496
0.002
0.287
57 (± 12) 54 (± 14) 0.078 Short Form Mental Component Summary Values given as mean and standard deviation, median and range, or number of patients and proportion. ASA = American Society of Anesthesiologists physical classification system; BMI = body mass index; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; SF-12 PCS = Short Form-12 physical component summary; SF-12 MCS = Short Form-12 mental component summary.
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Table 2. Adjusted odds ratios for the risk of dissatisfaction following primary total joint arthroplasty. Odds Ratio
Variable
1.012 0.998 1.242 4.143 1.312
WOMAC SF-12 MCS African American Race (ref: White)
P Value
95% Confidence Interval
0.193 0.850 0.643 0.033 0.430
0.994 0.972 0.497 1.122 0.670
1.030 1.024 3.105 15.304 2.571
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Hispanic/Latino Race (ref: White) Primary/Secondary Education (ref: Higher education) WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, SF-12 MCS: The 12-item Short Form Survey Mental Health Score.
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Table 3. Reasons for dissatisfaction following total hip arthroplasty. Reason for Dissatisfaction N (%) Persistent Pain 14 (41%) Functional Limitation 12 (35%) Surgical Complications/Reoperation 4 (12%) Staff/Quality of Care Issues 2 (6%) Slow Recovery 2 (6%)
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Table 4. Reasons for patient dissatisfaction following total knee arthroplasty. Reason for Dissatisfaction N (%) Persistent Pain 19 (41%) Functional Limitation 12 (26%) Surgical Complications/Reoperation 8 (17%) Staff/Quality of Care Concerns 5 (11%) Unmet Expectations 2 (4%)
S0883-5403(19)30120-2
DOI:
https://doi.org/10.1016/j.arth.2019.01.075
Reference:
YARTH 57055
To appear in:
The Journal of Arthroplasty
Received Date: 13 January 2019 Revised Date:
30 January 2019
Accepted Date: 31 January 2019
Please cite this article as: Halawi MJ, Jongbloed W, Baron S, Savoy L, Williams VJ, Cote MP, Patient Dissatisfaction after Primary Total Joint Arthroplasty: The Patient Perspective, The Journal of Arthroplasty (2019), doi: https://doi.org/10.1016/j.arth.2019.01.075. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Patient Dissatisfaction after Primary Total Joint Arthroplasty:
Mohamad J. Halawi, MD1 Walter Jongbloed, BS2 Samuel Baron, BS2
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Lawrence Savoy, BS1
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The Patient Perspective
Vincent J. Williams, MD1
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Mark P. Cote, DPT1
1. Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT
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2. University of Connecticut School of Medicine, Farmington, CT
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Corresponding Author: Mohamad J. Halawi, MD Department of Orthopaedic Surgery University of Connecticut Health Center 263 Farmington Ave Farmington, CT 06030 Phone: 860-679-3520
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Patient Dissatisfaction after Primary Total Joint Arthroplasty: The Patient Perspective
2 ABSTRACT
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Background: Despite improvements in surgical technique and implant longevity, some patients
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continue to report dissatisfaction following total joint arthroplasty (TJA). As patient satisfaction
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is increasingly used as a quality metric, the objective of this study was to gain better
7
understanding of satisfaction with TJA from the patient perspective.
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Methods: 551 primary total hip and knee arthroplasties (THA and TKA) with a minimum of 1-
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year follow-up and were responsive to a satisfaction survey were analyzed. The incidence,
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predictive factors, and subjective reasoning for patient dissatisfaction were assessed. Univariate
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and multivariate logistic regression analyses were performed.
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Results: Patient satisfaction was 89% for THA and 88% for TKA. Hispanic race was the most
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significant predictor of dissatisfaction (p=0.037). The most common reasons for dissatisfaction
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following THA were persistent pain (N=14/34, 41%), functional limitation (N=12/34, 35%),
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surgical complication/reoperation (N=4/34, 12%), staff or quality of care issues (N=2/34, 6%),
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and slow recovery (N=2/34, 6%). The most common reasons for dissatisfaction following TKA
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were persistent pain (N=19/46, 41%), functional limitation (N=12/46, 26%), surgical
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complication/reoperation (N=8/46, 17%), staff or quality of care issues (N=5/46, 11%), and
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unmet expectations (N=2/46, 4%).
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Conclusion: While persistent pain and functional limitation are the two leading reasons for
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dissatisfaction in both TKA and THA, a subset of patients view satisfaction as an evaluation of
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the process by which care is delivered. Patient satisfaction is not solely a reflection of surgical
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outcome and should be interpreted with caution. Potential for incomplete pain relief or full
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functional recovery should be discussed during preoperative counseling. Empathic care is also
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important and should be encouraged to enhance the overall patient experience.
26 Keywords:
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Arthroplasty, hip; knee; patient satisfaction; patient perspective; risk factors.
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29 Introduction
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Patient satisfaction is increasingly gaining significance as quality of care takes central stage in
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today’s healthcare environment. Among patients undergoing total joint arthroplasty (TJA),
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patient satisfaction rates as measured by questionnaires and interviews have ranged from 80% to
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93% [1-5]. While patient satisfaction is arguably the most important outcome, satisfaction is a
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curious term that may represent either an evaluation of the endpoint of care or the process by
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which care is delivered [6]. Some argue that patient satisfaction is more a measure of the latter,
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and therefore, the concept of patient satisfaction as a “customer service” metric should be
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assessed separately from surgical quality and safety metrics [7].
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Previous studies have explored several predictors of patient satisfaction after TJA although the
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vast majority of those studies were primarily focused on total knee arthroplasty [8-13]. Among
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the identified factors were age, sex, race, patient’s personality, comorbidities, severity of
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arthropathy, preoperative diagnosis (e.g., rheumatoid arthritis), mental disorders (e.g.,
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depression/anxiety), preoperative pain at rest, lower preoperative quality of life, and
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postoperative complications requiring readmission [1, 8-10, 12]. Another cause of dissatisfaction
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that has garnered increased attention is failure to meet preoperative expectations [2, 14]. To date,
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no studies have attempted to explore patient satisfaction subjectively from the patient
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perspective, which may provide more insights into this quality metric. If patient satisfaction is to
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factor into evaluation and reimbursement, providers must fully understand this metric.
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The purpose of this study was to gain better understanding of why some patients are not satisfied
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with TJA by directly inquiring the reasons from them. The research questions are: 1) What are
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the satisfaction rates in patients undergoing primary TJA with a minimum of 1-year follow-up?
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What baseline characteristics exist between patients who are satisfied or not satisfied? What are
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the perspectives of patients who are not satisfied? Is patient satisfaction an evaluation of the
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endpoint of care or the process by which care is delivered?
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57 Methods
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Our IRB-approved prospectively collected institutional joint database was retrospectively
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reviewed for all patients who underwent primary THA and TKA with a minimum of one-year
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follow-up. The database was established in 2012 and includes primary and revision cases
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performed by fellowship trained surgeons. Between 2012 and 2017, five surgeons contributed
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their cases to the registry. Our institution is a public academic center. Patient inclusion in the
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database is voluntary and requires consent and willingness to participate in regular surveys. Non-
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elective, tumor-related, and simultaneous bilateral procedures were excluded. In addition, to
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avoid potential confounding effects, patients undergoing a second arthroplasty in another joint
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(hip or knee) within 12 months were excluded. 780 eligible patients were identified. Those
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patients were then contacted via telephone to inquire about their satisfaction with surgery. 477
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patients (61%) who underwent 551 procedures were responsive and included in the analysis.
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Patient satisfaction was assessed by a medical student who received prior training and was
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provided a standardized script to follow when contacting patients via telephone. Patients were
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specifically asked “Are you satisfied with your total hip or knee replacement?” If any indicated
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that they were not satisfied, they were then asked “Mr./Ms. ___, please help me understand why
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you are not satisfied.”
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Preoperative information collected were age, sex, body mass index (BMI), insurance type
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(Medicaid, Medicare, commercial, and worker’s compensation), American Society of
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Anesthesiologist physical classification (ASA), marital status (married/living with a significant
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other vs. living alone/without a significant other), educational attainment (primary/secondary
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school vs. college/university), race (White, Black, Hispanic, or other), smoking status,
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(never/former vs. active), history of clinical diagnosis of depression, disease-specific health
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status (as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index,
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WOMAC), mental health wellbeing (as assessed by the Short Form-12 mental component
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summary, SF-12 MCS), and physical health wellbeing (as assessed by the Short Form-12
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physical component summary, SF-12 PCS). Two cohorts were analyzed: 1) those who were
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satisfied and 2) those who were not satisfied. The primary outcomes of the study were the
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incidence, predictive factors, and subjective reasoning for dissatisfaction. Patient responses were
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carefully read and used to construct a category system, thereby allowing us to systematically
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categorize the qualitative data. Each reason for dissatisfaction was assigned one point. Responses
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in each category had to be clearly and unequivocally related. Patients who indicated multiple
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reasons for dissatisfaction were assigned a point for each reason. The top five categories were
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reported. There were no significant changes in surgical technique or anesthesia during the time
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period study with the exception of multimodal analgesia, which was implemented in 2016.
94 Descriptive statistics including mean and standard deviation for clinical outcome scores
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(WOMAC, SF-12, etc.), age, and BMI, median and range for ASA class, and frequency and
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proportion for sex, education, martial status, race, smoking status, depression, and insurance type
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were calculated to characterize the study groups. Continuous data was examined graphically and
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appeared to follow a normal distribution. Preoperative differences between the satisfied and
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dissatisfaction groups were examined with the independent t test or Mann Whitney test (for ASA
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class) for continuous variables and the chi-square or Fisher’s exact test for categorical variables.
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The difference in the proportion of patients who were dissatisfied before and after the time
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addition of multimodal analgesia was compared to account for this variable. A mixed effects
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logistic regression model was constructed to examine the impact of baseline differences on the
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study outcome. Univariate analysis was performed to identify variables associated with
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satisfaction. Those variables with a p value less than or equal to 0.1 or those known to be
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associated with clinical outcome (ASA score) were included in a multivariable regression model.
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Adjusted odds ratios are presented with corresponding 95% confidence intervals (95% CI).
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Statistical significance was set at p<0.05. All analysis was performed with Stata 15 software
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(StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC).
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Results
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551 procedures were analyzed (275 THAs and 276 TKAs). Patient satisfaction rates following
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THA and TKA were 89% and 88% respectively at a mean follow-up of 41.0 months (range 12–
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72 months). There were no differences in age (p = 0.395), sex (p = 0.558), ASA class (p =
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0.285), BMI (p = 0.844), educational attainment (p = 0.054), marital status (p = 0.496), SF-12
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PCS (p = 0.105), or SF-12 MCS (p = 0.078) between those who were satisfied or not (487 vs.
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64). However, patients who were not satisfied were more likely to be of Hispanic race (p=0.002)
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and have poorer WOMAC score (p=0.004). There was no difference in dissatisfaction before or
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after the implementation of multimodal analgesia (12% vs. 11%, p=0.760). Table 1 summaries
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the baseline characteristics of the study cohorts.
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Table 2 summarizes the results of the multivariate regression analysis. In this analysis, only
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Hispanic race remained a significant predictor of dissatisfaction relative to White race (OR
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4.143, 95% CI 1.122–15.304, p = 0.033). When African American race was used as a reference,
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Hispanic race remained more predictive of dissatisfaction although this did not reach statistical
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significance (OR 3.376, 95% CI 0.754–15.114, p = 0.112).
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All dissatisfied patients provided their perspectives on why they were not satisfied with surgery.
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The most common reasons for dissatisfaction following THA were persistent pain (N=14/34,
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41%), functional limitation (N=12/34, 35%), surgical complication/reoperation (N=4/34, 12%),
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staff or quality of care issues (N=2/34, 6%), and slow recovery (N=2/34, 6%). The most common
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reasons for dissatisfaction following TKA were persistent pain (N=19/46, 41%), functional
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limitation (N=12/46, 26%), surgical complication/reoperation (N=8/46, 17%), staff or quality of
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care issues (N=5/46, 11%), and unmet expectations (N=2/46, 4%). Tables 3 and 4 summarize the
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top 5 reasons for dissatisfaction following THA and TKA respectively.
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Discussion
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In this study, we sought to gain better understanding of predictive factors and subjective reasons
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for patient dissatisfaction following TJA. 89% and 88% of patients were satisfied with their THA
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and TKA respectively. Hispanic race was the most significant predictor of patient dissatisfaction.
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To date, there is limited information about the effect of race on TJA outcomes; and to our
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knowledge, this is the first study to report on the effect of Hispanic race. In a systematic review
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of patients undergoing TKA, Goodman et al [15] found that only 7 of 5127 studies screened
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(0.001%) included race in their analysis. In those studies, US blacks were found to have lower
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satisfaction rates at 6–24 months postoperatively. In another systematic review by Bass et al
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[16], US blacks were at higher risk for revision TKA than whites. In this study, while Black race
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was also associated with higher rates of dissatisfaction, Hispanic race was found to be most
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predictive of dissatisfaction.
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Persistent pain was the most common cause for dissatisfaction (41% for both THAs and TKAs).
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Persistent pain has been frequently cited as a major cause of patient dissatisfaction although an
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adequate medical explanation for this complaint is often lacking [1, 11, 17]. Vasileios et al [18]
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retrospectively reviewed 272 patients who underwent primary TKA at a minimum follow-up of 1
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year. 39% of patients reported persistent pain ranging from 3–5 out of 10. Length of surgical
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procedure, patellofemoral joint overstuffing, diabetes mellitus, and preoperative flexion
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contracture were identified as risk factors. In another retrospective review of 1030 patients
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undergoing primary TJA at a minimum of 1 year follow-up, Liu et al [19] found the rates of
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persistent pain were 38% and 53% for THA and TKA respectively. The authors identified female
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sex, younger age, previous hip or knee surgery, presence of pain in other areas of the body, and
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inadequate postoperative pain control to be predictive of incomplete pain relief.
162 As persistent pain and functional limitation rank among the top two reasons for dissatisfaction in
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this study, a synergistic effect between these factors should be considered. For example, pain-
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related fear of movement has been shown to be predictive of postoperative functional difficulties
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[20]. Other predictors of activity limitation after primary TJA are BMI > 35, depression, age >
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70 years, female sex, and ipsilateral lower extremity joint involvement [21, 22].
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A small proportion of patients reported dissatisfaction with the care they received in the hospital
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or immediate postoperative period following TJA. This is an interesting observation and
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indicates that patient satisfaction is not just a reflection of the surgical procedure itself. Despite
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assessing patient satisfaction at least one year from surgery, dissatisfaction with immediate
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surgical care lingered in 6% and 11% in patients undergoing THA and TKA respectively.
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Responses included dissatisfaction with members of the health care team, including surgeons,
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nurses, and physical therapists. The degree to which patient satisfaction with the care received
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from the health care team correlates with outcomes is a subject of ongoing research. Hamilton et
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al [2] reviewed a prospective cohort of 4709 patients undergoing primary TJA and found that
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satisfaction with the hospital experience was a major predictor of the patient’s overall
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satisfaction after TJA. More recently, in a retrospective review of 692 patients who underwent
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primary THA, Mistry et al [23] found that patients’ perception of their treating nurses and
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orthopaedic surgeons significantly correlated with how they rated their hospital experience.
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Although our respondents did not report unmet expectations as a major reason for dissatisfaction,
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this outcome is likely a component of other reasons for dissatisfaction. In other words, patients
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who report persistent pain or functional limitation likely also have unmet expectations.
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Substantial research has emphasized the importance of meeting expectations in patient
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satisfaction [1, 14, 24]. As patient expectation is a modifiable factor, initiatives to better inform
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those expectations may contribute to higher rates of satisfaction.
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This study has several strengths and limitations. Research has shown that although large
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functional improvements are achieved within the first 3 months post surgery, continued
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improvement can be seen up to a year [27]. Assessing satisfaction at or greater than the one-year
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mark is therefore a major strength of this study. In addition, we used open ended questions to
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allow patients to freely explain the reasoning behind their dissatisfaction. One potential
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shortcoming, however, is that data collection relied upon patient recall and did not provide a
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comprehensive symptomatic history for any one patient. However, many patients reported
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reasons for dissatisfaction that were ongoing, such as persistent pain and functional limitation.
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Another limitation is only 61% of eligible patients were responsive to the satisfaction survey.
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In conclusion, patient satisfaction following TJA proved to be a complex outcome metric to
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assess. Patient satisfaction is influenced by non-modifiable characteristics (e.g., race). It is also a
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reflection of both the response to the surgical procedure (persistent pain and/or functional
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limitation) and quality of “service” rendered by members of the care team (surgeons, nurses, and
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physical therapists). Patient satisfaction is not solely a reflection of surgical outcome and should
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be interpreted with caution. The potential for incomplete pain relief and full functional recovery
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should be discussed during preoperative counseling. Further studies should be directed to
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correlate the responsiveness of existing patient reported outcome measures (PROMs) to patient
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satisfaction. As patient satisfaction plays a greater role in reimbursement, selecting appropriate
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PROMs that allow detection of poor responders, especially in pain and function domains, may
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allow early intervention to improve satisfaction with surgery. Last but not least, empathic care is
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important and should be encouraged to enhance the overall patient experience.
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Table 1. Baseline characteristics of the study cohorts.
Age (years)
Not Satisfied
487
64
60.9 (± 11.7)
59.6 (± 11.1)
Sex Female
255 (52%)
Male
232 (48%)
P value
0.395
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Satisfied
36 (56%)
0.558
2 (1-4)
American Society of Anesthesiologists Classification System 2
Education
2 (1-3)
0.285
31.0 (± 5.0)
0.844
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31.1 (± 5.3)
Body Mass Index (kg/m )
28 (44%)
214 (46%)
36 (59%)
College/University
252 (54%)
25 (42%)
M AN U
Primary/Secondary School
Marital Status
0.054
Married/Living with a Significant Other
213 (45%)
31(50%)
Living Alone/Without a Significant Other
256 (55%)
31 (50%)
White
371 (76%)
39 (61%)
Black/African American
72 (15%)
10 (16%)
Hispanic/Latino
28 (6%)
12 (19%)
16 (3%)
3 (5%)
14 (22%)
110 (23%)
0.898
Never/Former Active
402 (87%) 62 (13%)
48 (77%) 14 (23%)
0.052
Medicaid
124 (30%)
24 (41%)
Medicare
164 (40%)
21 (36%)
Commercial
118 (29%)
13 (22%)
6 (1%)
0
Western Ontario and McMaster Universities Osteoarthritis Index
57 (± 21)
65 (± 21)
0.004
Short Form-12 Physical Component Summary
28 (± 9)
26 (± 9)
0.105
TE D
Race
Depression Smoking Status
AC C
Insurance Type
EP
Other
Worker’s Compensation
0.496
0.002
0.287
57 (± 12) 54 (± 14) 0.078 Short Form Mental Component Summary Values given as mean and standard deviation, median and range, or number of patients and proportion. ASA = American Society of Anesthesiologists physical classification system; BMI = body mass index; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; SF-12 PCS = Short Form-12 physical component summary; SF-12 MCS = Short Form-12 mental component summary.
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Table 2. Adjusted odds ratios for the risk of dissatisfaction following primary total joint arthroplasty. Odds Ratio
Variable
1.012 0.998 1.242 4.143 1.312
WOMAC SF-12 MCS African American Race (ref: White)
P Value
95% Confidence Interval
0.193 0.850 0.643 0.033 0.430
0.994 0.972 0.497 1.122 0.670
1.030 1.024 3.105 15.304 2.571
AC C
EP
TE D
M AN U
SC
RI PT
Hispanic/Latino Race (ref: White) Primary/Secondary Education (ref: Higher education) WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, SF-12 MCS: The 12-item Short Form Survey Mental Health Score.
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AC C
EP
TE D
M AN U
SC
RI PT
Table 3. Reasons for dissatisfaction following total hip arthroplasty. Reason for Dissatisfaction N (%) Persistent Pain 14 (41%) Functional Limitation 12 (35%) Surgical Complications/Reoperation 4 (12%) Staff/Quality of Care Issues 2 (6%) Slow Recovery 2 (6%)
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AC C
EP
TE D
M AN U
SC
RI PT
Table 4. Reasons for patient dissatisfaction following total knee arthroplasty. Reason for Dissatisfaction N (%) Persistent Pain 19 (41%) Functional Limitation 12 (26%) Surgical Complications/Reoperation 8 (17%) Staff/Quality of Care Concerns 5 (11%) Unmet Expectations 2 (4%)