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Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)–A prospective study
Journal of Orthopaedic Science xxx (2017) 1e6
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study Teng Lijia a, b, 1, Zeng Rui-Xi d, 1, Gong Long c, 1, 3, Chen Lei c, Liu Yujie a, *, 2, He Jin-Yun d, **, 2, Wang Zhen-Hu c, ***, 2 a
Chinese PLA General Hospital, Beijing, 100853, China The 261st Hospital of Chinese PLA, Beijing, 100094, China 252 Hospital of Chinese PLA, No. 991 Baihua East Road, Beishi District, Baoding City, Hebei, 071000, China d Department of Plastic and Reconstructive Surgery, First Affiliated Hospital Sun Yat-sen University, Guangzhou, 510080, China b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 December 2016 Received in revised form 22 March 2017 Accepted 23 May 2017 Available online xxx
Background: The interaction between patients is rather important source of information about surgery and recovery. Patients always prefer particularly to compare themselves with others of relatively similar ability, opinion and situation. Exploration of patients' dyads, however, is rare and needs further elaboration as to the significance of fellow patients. This study was designed to determine in whether and how preoperative assignment affects TKA's results. Methods: We assessed early post-operative outcomes in a cohort of 520 TKA patients. Preoperative, and postoperative outcome measures at 6-months following TKA were analyzed and compared between patients who were hospitalized with a roommate whose surgical status was either similar (preoperative) or dissimilar (postoperative) and whose type of surgery was either similar (TKA) or dissimilar (THA). Mean scores, and postoperative change in scores were calculated. Outcome measures evaluated included WOMAC, SF-36, patient affiliation, preoperative anxiety, expectation and analgesic consumption, length of hospital stay. Results: patients were more willing to have serious conversations with roommates whose surgical status was dissimilar (postoperative) and whose type of surgery was similar (TKA). And their SF-36 and WOMAC scores to be significantly improved better. Besides, they were released from hospital more quickly and showed significantly less preoperative anxiety. Conclusions: We recommend implementation of an assignment policy that patients prior to TKA should be assigned into a postoperative roommate undergoing TKA as well. © 2017 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
1. Introduction A few published reports have demonstrated that the doctorpatient communication can influence clinical outcomes [1e3]. In addition to patientedoctor relationship, other social interactions in
* Corresponding author. ** Corresponding author. *** Corresponding author. E-mail addresses: [email protected] (G. Long), [email protected] (L. Yujie), [email protected] (H. Jin-Yun), [email protected] (W. Zhen-Hu). 1 These authors contributed to the work equally. 2 Liu Yujie, He Jin-Yun, Wang Zhen-hu are the corresponding authors and contributed to the work equally. 3 Note: Gong Long is not a corresponding author but a contact person in the production section.
ward such as the relationship between nurses, doctors [1,2], patients [3] and their family members [4,5] have been a rising concern. Thereinto, exploration related to patientepatient dyad is rare and needs further elaboration as to the significance of fellow patients in sharing information, supportive relationship and affiliation when facing the threatening total knee arthroplasty (TKA). In the US, “Joint Camps” have been popularized to allow TJA candidates to interact in preoperative teaching sessions as well as group rehabilitation sessions during hospitalization and have been shown to be quite successful [1,6,7]. To our best knowledge, powerful evidence supporting the practice in orthopedic field is absent. The premise of having patients interact, educate and reassure each other is intriguing. A few reports indicated that information patients grasp prior to surgery helps achieve three goals: participating in decision making
http://dx.doi.org/10.1016/j.jos.2017.05.016 0949-2658/© 2017 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
about treatment, improving postoperative recovery and reducing situational anxiety [1,7,8]. However, the ideal way of providing preoperative information is still unclear [6e8]. Of note, patients increasingly turn to their fellow patients for knowledge and information instead of turning to the healthcare professionals [9]. Healthcare professionals are perceived as less credible than fellow patients because they have not experienced similar conditions. Consequently, the patientepatient interaction is rather important source of information [10,11]. However, patients tend not to discuss their disease with fellow patients in different situations and experience less social support from them [8]. In brief, people always prefer particularly to compare themselves with others of relatively similar ability, opinion and situation, which are further summarized as “similarity hypothesis” in social psychology [8,10,11]. From this perspective, roommates could be a potential and natural resource to educate and benefit the patients undergoing total joint arthroplasty (TJA) [8]. By means of above-mentioned theory, whether and how roommate status could affect the other patient's recovery from TJA is worthy of being investigated. To explore possible “roommate effect”, we decided to select patients undergoing TKA. Two aspects of roommate similarity/dissimilarity that is particularly salient to a preoperative patient are surgical status and operative type of his or her roommate respectively. Therefore, the overarching aims of this study were to compare directly the effects of two independent angles of roommate similarity on TKA's results by assigning preoperative patients prepared to undergo TKA to a roommate whose surgical status was either similar (preoperative) or dissimilar (postoperative) and whose type of operation was either similar (TKA) or dissimilar (THA). We hypothesized that roommate’ condition affected TKA's results. 2. Methods and patients 2.1. Participants 520 eligible subjects prepared for a unilateral and primary TKA due to degenerative knee joint osteoarthritis were enrolled. As the type of anesthesia may affect outcome, only patients who received epidural anesthesia were included. The patient would be excluded if he or she had a history of knee sepsis, high tibial osteotomy, knee flexion contracture, varus/valgus deformity of greater than 20 , less than 90 degrees of knee flexion, neurological disease, mental disorder, major surgery or affective disorder. All these would produce a significant difference from their roommate. Patients unwilling to participate in this study and refusing to a double room were also excluded. 2.2. Study design We performed a randomized and controlled study comparing the effect of patients' dyads during hospitalization from October 2011 to May 2013 in Chinese PLA General Hospital, 252 Hospital of Chinese PLA and First Affiliated Hospital Sun Yat-sen University. Ethical approval from the Institutional Review Board (IRB) of these three institutions and written informed consent from participants were obtained prior to the initial assessment. Randomization codes were stored in sequentially numbered opaque envelopes that were opened before admission. 2.3. Intervention Participants were randomly allocated to accept two different preoperative assignment policies according to the roommates' surgical status (pre-op vs post-operation) and the type of operation (TKA vs THA). A patient shared a room with the same roommate
until discharge and we did not change their roommate in hospital. Each patient received the same routine preoperative preparation from the hospital staff. Meanwhile, we made each ward environment identical. Participants were asked to complete required questionnaires (see Evaluation and Outcomes). Either of epidural anesthesia or nerve block was used for surgery. All TKA and THA procedures were performed by three experienced surgical teams [Liu Yujie, He Jin-Yun and Wang Zhen-Hu]. Cruciate ligamentretaining prosthesis (Gemini, Link, Germany) or uncemented hip prosthesis (Ribbed, Link, Germany) were utilized in TKA and THA respectively. Staffs that designed the study and recorded the results were blinded to the study. Thromboprophylaxis protocol was 10 mg rivaroxaban per day. Analgesic consumption included total doses of opioid and Non-Steroidal Anti-inflammatory Drugs (NSAIDs) painkillers. 2.4. Evaluation and Outcomes 1 Physical status: Short Form Health Survey (SF-36) and Western Ontario McMaster Osteoarthritis Index (WOMAC). To document the recovery status and the benefits of TJA, we decided to use SF-36 and WOMAC questionnaire, which can comprehensively document clinical and subjective improvement after joint replacement and reveal its difference. Participants were assessed before surgery and in the six months postoperatively by one clinician blinded to group allocation. 2 Patient affiliation Participants were required to estimate the number of hours they had spent talking with their respective roommate. A patientreported questionnaire on separate 4-point scales that ranged from not at all [1] to very much so [4] was applicated to assess patient affiliation three aspects including cognitive clarity, emotional comparison, and emotional support. Those were assessed in the six months postoperatively. Relevant to cognitive clarity, patients were asked to indicate the extent to which they (a) discussed with their roommate how it would feel after TKA, (b) discussed ways to make recovery and exercise easier, (c) learned things by watching their roommate that would be helpful for their own recovery, (d) learned things by talking to their respective roommate that would be helpful for their own recovery, and (e) felt they had “a better idea of what to expect after TKA” because of their roommate. In an effort to assess emotional comparison activity, we also asked patients to indicate the extent to which they (a) mentioned to their roommate how they felt emotionally about joint replacement (e.g., how calm or nervous), (b) thought about how nervous their roommate seemed compared with themselves, and (c) were told by their roommate how he felt emotionally about his joint replacement (e.g., how calm or nervous). To assess emotional support affiliations, we asked patients to indicate the extent to which (a) their roommate said things to them in an effort to make them feel better about their TKA (e.g., “things will be all right”), (b) they said things to their roommate in an effort to make him feel better about his TKA, and (c) they liked joking with their roommate about their TKAs [12]. 3 Psychological status: preoperative anxiety and expectation Patients completed a short (10-item) form of the State version of the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, &
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
Lushene, 1970), which provides a valid measure of state anxiety. Satisfaction of patients undergoing TKA was assessed using a 100mm visual analog scale, ranging from 0 ¼ highly dissatisfied to 100 ¼ completely satisfied. Both anxiety and expectation were evaluated in the evening before surgery. 4 Analgesic consumption and length of hospital stay Analgesic consumption during early postoperative periods (two weeks after TKA) and length of hospital stay in this study was also recorded.
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2.5. Statistical methods Significance threshold was defined as 0.05, that is, P-value. The number of 120 subjects in each group was enough to detect a 20% reduction between groups with alpha 0.05 and beta 0.1. The power analysis using Power and Sample Size Calculation was calculated to be 90%. Descriptive statistics (means, standard deviations and proportions) were showed for all study variables. We evaluated the change between groups using Student t-test. All analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, Illinois, USA).
Fig. 1. Flow chart of enrolled participants.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
Table 1 Demographic characteristics and baseline information. Variables
Assignment based on surgical status
Patient characteristics Age (years) Sex (male/female) BMI (kg/m2) Preoperative data Pain at rest ROM SF-36 WOMAC Surgery Duration of surgery (min) Duration of femoral tourniquet (min) Surgical teams (Liu Yujie/He Jin-Yun/Wang Zhen-Hu)
PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
64.8 (5.3) 12/107 27.1 (3.2)
66.1 (5.9) 10/108 27.5 (3.5)
2.8 (0.8) 108.2 (11.3) 68.2 (10.2) 46.9 (11.8) 66.3 (5.8) 28.7 (4.8) 40/45/34
P value
Assignment based on type of operation
P value
KK group (n ¼ 118)
KH group (n ¼ 119)
0.08 0.84 0.36
63.6 (7.2) 13/105 28.4 (3.3)
65.1 (7.5) 14/105 29.0 (3.1)
0.12 0.98 0.15
2.9 (0.7) 110.4 (10.8) 70.2 (11.1) 48.6 (10.8)
0.31 0.13 0.15 0.25
2.6 (1.0) 110.1 (10.8) 66.5 (11.2) 47.3 (11.5)
2.7 (0.9) 108.6 (9.8) 68.2 (12.0) 48.0 (10.8)
0.42 0.26 0.26 0.63
67.2 (7.5) 29.2 (5.0) 38/43/37
0.30 0.43 0.90
65.4 (6.2) 28.8 (4.8) 39/48/31
65.8 (6.4) 27.9 (5.2) 43/39/37
0.63 0.17 0.44
Values in parentheses are SD. t-test used for all the statistical analysis.
tended to take fewer pain medications after TKA and be released from hospital more quickly (Table 4).
3. Results Finally, 480 subjects completed the trial and were analyzed according to the ‘intention-to-treat’ principle (Fig. 1). The four groups were similar in baseline characteristics (Table 1). 3.1. Physical status: SF-36 and WOMAC scores In general, there was some tendency for SF-36 and WOMAC scores to be significantly improved better when participants were assigned to a roommate whose type of surgery was similar (TKA). However, there was no significant difference between two groups dichotomized according to surgical status (Table 2). 3.2. Patient affiliation In the six months postoperatively patients preferred to stay in touch with their respective roommates who was postoperative and underwent TKA in comparison to who was preoperative and underwent THA (Table 3). More estimated number of hours patients spent talking to their roommate was recorded when they had a roommate who was postoperative and underwent TKA as well. Besides, scores of their affiliation in three aspects tended to be higher (Table 3).
4. Discussion The factor that assignment policy could affect TKA's early recovery was rarely investigated before. Our findings were quite consistent. Both the surgical status and operative type of the roommate exerted important effects on TKA's results. Specifically if patients were randomly assigned preoperatively to a roommate who was recovering from TKA (identical surgery and different surgical status), they tended to (a) have a closer affiliation reflected by three aspects (cognitive clarity, emotional comparison and emotional support) with their respective roommate, (b) be less situational anxiety, (c) have more appropriate expectation prior to their TKA, (d) take fewer pain medications after TKA, (e) be sooner released from the hospital, and (f) show better WOMAC and SF-36 scores in patients who shared a room with a patient undergoing TKA as well. Thus, preoperative patients tend to interact with a postoperative roommate undergoing TKA not THA. Possible explanations are that “roommate effect” mainly originates from characteristics of physical and psychological condition in both sides in the same ward:
3.3. Psychological status: preoperative anxiety and expectation
(a). Patients wanted access to as much information as possible through multiple channels, e.g., the Internet, consultation with doctors and communication with patients. The study conducted by Regner Baekeland indicated patients clearly emphasized the importance of interpersonal interaction with fellow patients when it came to care, support and illness information [12,13]. However, it should be stressed here that patients don't casually select a fellow patient to talk with their conditions and feelings. Interaction questionnaire's results suggested that patients before TKA were more willing to seek information about upcoming TKA from patients who had experienced that (a roommate accepted TKA
Their expectation was significantly higher when patients had a roommate who was preoperative and underwent the different surgery, THA. Prior to their surgery, patients were less anxious if they had a roommate who was postoperative rather than likewise preoperative and underwent TKA as well rather than THA (Table 4). 3.4. Analgesic consumption and length of hospital stay Those patients who preoperatively shared a room with a postoperative patient or a patient undergoing the same operation Table 2 Effects of roommate condition on SF-36 and WOMAC scores. Variables
SF-36 WOMAC
Assignment based on surgical status PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
71.3 (9.8) 40.2 (6.8)
70.5 (10.1) 41.1 (7.6)
P value
0.54 0.34
Assignment based on type of operation KK group (n ¼ 118)
KH group (n ¼ 119)
70.8 (8.9) 39.8 (5.4)
68.1 (9.5) 41.5 (6.1)
P value
0.02* 0.02*
Values in parentheses are SD. t-test used for all the statistical analysis. * means there was a statically significant difference between groups.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
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Table 3 Patient affiliation as a function of operation type and operative status of roommate. Variables
Number of patients staying in touch with their respective roommate Number of talking hours Cognitive clarity Emotional comparison Emotional support
Assignment based on surgical status PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
76
12
4.3 (2.3) 15.8 (3.1) 8.6 (2.7) 8.4 (2.6)
3.5 (2.2) 13.3 (2.9) 6.5 (2.5) 7.0 (2.4)
P value
Assignment based on type of operation
P value
KK group (n ¼ 118)
KH group (n ¼ 119)
<0.001*
72
18
<0.001*
0.007* <0.001* <0.001* <0.001*
5.2 (2.1) 16.6 (2.7) 9.4 (2.3) 10.2 (1.8)
4.3 (2.5) 10.2 (3.5) 5.8 (2.5) 6.1 (2.4)
0.003* <0.001* <0.001* <0.001*
Values in parentheses are SD. t-test used for all the statistical analysis. *means there was a statically significant difference between groups.
Table 4 Effects of roommate condition on other TKA's clinical outcomes. Variables
Assignment based on surgical status
P value
PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
Preoperative Anxiety Expectation Pain medications consumption Length of hospital stay
21.1 (3.6) 91.3 (3.3) 190.2 (45.3) 5.5 (0.9)
25.6 (4.2) 96.2 (3.2) 205.1 (48.3) 5.9 (1.0)
<0.001* <0.001* 0.02* 0.001*
Assignment based on type of operation KK group (n ¼ 118)
KH group (n ¼ 119)
22.3 (3.2) 90.2 (2.8) 193.6 (47.3) 5.3 (0.8)
24.8 (3.6) 96.8 (3.1) 207.5 (49.8) 5.6 (1.0)
P value
<0.001* <0.001* 0.03* 0.01*
Values in parentheses are SD. t-test used for all the statistical analysis. *means there was a statically significant difference between groups.
and was postoperative). Possible explanations for that could be that people in uncertain or stressful situations will prefer to affiliate with similar others instead of dissimilar ones. (b). In this study, patients showed a significant decrease in anxiety and were released from hospital sooner when they were assigned to a roommate who was postoperative and accepted the same surgery. Possible explanations were that these patients generally knew their postoperative conditions well and more objectively, which benefited from direct communication with patients in similar conditions. Wallace reported that patients with more knowledge about surgery have fewer worries and recover faster [14]. (c). Patients generally tend to have exorbitant expectation before surgery, which may decrease satisfaction. Moderate expectation builds on learning about what's expected side effects and discomforts in advance through observation and/or interaction with a postoperative roommate than a similarly preoperative roommate and with a roommate undergoing similar surgery than different surgery. (d). As for less pain and pain medication consumption, corresponding mechanism could be set up due to powerful
encourage and support between patients. Numerous studies have demonstrated that pain was significantly associated with negative emotions [9,12]. Positive emotions helped ease anxiety and distract from the pain feelings and physical discomforts. (e). Interestingly, patients showed better WOMAC and SF-36 scores in the six months postoperatively if they had a roommate who accepted a similar arthroplasty (TKA). Duration of share the same ward in hospital was merely couples of days (Table 4). However, unexpectedly it seemed that “roommate effect” lasted six months. Our explanation was that 63.9% (76/119) of them stayed in touch with their respective roommates by phone according to patientreported results. The advantages of our study lied in its designda prospective and randomized study with a relatively large sample. This was the first study to investigate effects of assignment policy of preoperative patients on TKA's results. We evaluated TKA's results from several aspects such as length of stay in hospital, WOMAC, ShortForm 36 scores and pain-related problems. These reflected TKA's
Fig. 2. Flow chart of advised assignment.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
cost-effectiveness and patients' quality of life, which were crucial parts of TKA's results. The implications of this study lies in that “roommate effect” helps reduce length of stay in hospital. It could be advisable for Medicare and patients to apply this assignment policy which reduce medical costs (Fig. 2). There were a certain limitations in our study. It was not clear how TKA's results would turn out to be for these patients who were in a ward alone or with several patients. Specifically, in countries or centers that have patients share rooms, our results of this study may be relevant; however in many settings patients occupy private rooms and do not have this roommate interaction. Besides, consecutive patients who waited for TKA were enrolled in this study. As a result, the ratio of women/men was larger than 10:1. Our conclusions could be merely used for women. Lastly, we analyzed only the effects for the TKA's results of preoperative assignment. Therefore, the present assignment policy was recommended for patients prior to TKA. Whether it was effective for patients accepting other surgery needs a pending further investigation.
5. Conclusion Sharing the ward in hospital with one patient after TKA or postoperative patient benefited recovery from TKA by improving functional scores, pain scores, anxiety and expectation. Therefore, we advise implementation of an assignment policy that patients prior to surgery should be hospitalized with a roommate whose surgical status was dissimilar (postoperative) and whose type of surgery was similar (TKA).
Competing interest None declared.
Acknowledgements We thank the patients who participated in this study and the staff involved in this work.
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Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study Teng Lijia a, b, 1, Zeng Rui-Xi d, 1, Gong Long c, 1, 3, Chen Lei c, Liu Yujie a, *, 2, He Jin-Yun d, **, 2, Wang Zhen-Hu c, ***, 2 a
Chinese PLA General Hospital, Beijing, 100853, China The 261st Hospital of Chinese PLA, Beijing, 100094, China 252 Hospital of Chinese PLA, No. 991 Baihua East Road, Beishi District, Baoding City, Hebei, 071000, China d Department of Plastic and Reconstructive Surgery, First Affiliated Hospital Sun Yat-sen University, Guangzhou, 510080, China b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 December 2016 Received in revised form 22 March 2017 Accepted 23 May 2017 Available online xxx
Background: The interaction between patients is rather important source of information about surgery and recovery. Patients always prefer particularly to compare themselves with others of relatively similar ability, opinion and situation. Exploration of patients' dyads, however, is rare and needs further elaboration as to the significance of fellow patients. This study was designed to determine in whether and how preoperative assignment affects TKA's results. Methods: We assessed early post-operative outcomes in a cohort of 520 TKA patients. Preoperative, and postoperative outcome measures at 6-months following TKA were analyzed and compared between patients who were hospitalized with a roommate whose surgical status was either similar (preoperative) or dissimilar (postoperative) and whose type of surgery was either similar (TKA) or dissimilar (THA). Mean scores, and postoperative change in scores were calculated. Outcome measures evaluated included WOMAC, SF-36, patient affiliation, preoperative anxiety, expectation and analgesic consumption, length of hospital stay. Results: patients were more willing to have serious conversations with roommates whose surgical status was dissimilar (postoperative) and whose type of surgery was similar (TKA). And their SF-36 and WOMAC scores to be significantly improved better. Besides, they were released from hospital more quickly and showed significantly less preoperative anxiety. Conclusions: We recommend implementation of an assignment policy that patients prior to TKA should be assigned into a postoperative roommate undergoing TKA as well. © 2017 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
1. Introduction A few published reports have demonstrated that the doctorpatient communication can influence clinical outcomes [1e3]. In addition to patientedoctor relationship, other social interactions in
* Corresponding author. ** Corresponding author. *** Corresponding author. E-mail addresses: [email protected] (G. Long), [email protected] (L. Yujie), [email protected] (H. Jin-Yun), [email protected] (W. Zhen-Hu). 1 These authors contributed to the work equally. 2 Liu Yujie, He Jin-Yun, Wang Zhen-hu are the corresponding authors and contributed to the work equally. 3 Note: Gong Long is not a corresponding author but a contact person in the production section.
ward such as the relationship between nurses, doctors [1,2], patients [3] and their family members [4,5] have been a rising concern. Thereinto, exploration related to patientepatient dyad is rare and needs further elaboration as to the significance of fellow patients in sharing information, supportive relationship and affiliation when facing the threatening total knee arthroplasty (TKA). In the US, “Joint Camps” have been popularized to allow TJA candidates to interact in preoperative teaching sessions as well as group rehabilitation sessions during hospitalization and have been shown to be quite successful [1,6,7]. To our best knowledge, powerful evidence supporting the practice in orthopedic field is absent. The premise of having patients interact, educate and reassure each other is intriguing. A few reports indicated that information patients grasp prior to surgery helps achieve three goals: participating in decision making
http://dx.doi.org/10.1016/j.jos.2017.05.016 0949-2658/© 2017 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
about treatment, improving postoperative recovery and reducing situational anxiety [1,7,8]. However, the ideal way of providing preoperative information is still unclear [6e8]. Of note, patients increasingly turn to their fellow patients for knowledge and information instead of turning to the healthcare professionals [9]. Healthcare professionals are perceived as less credible than fellow patients because they have not experienced similar conditions. Consequently, the patientepatient interaction is rather important source of information [10,11]. However, patients tend not to discuss their disease with fellow patients in different situations and experience less social support from them [8]. In brief, people always prefer particularly to compare themselves with others of relatively similar ability, opinion and situation, which are further summarized as “similarity hypothesis” in social psychology [8,10,11]. From this perspective, roommates could be a potential and natural resource to educate and benefit the patients undergoing total joint arthroplasty (TJA) [8]. By means of above-mentioned theory, whether and how roommate status could affect the other patient's recovery from TJA is worthy of being investigated. To explore possible “roommate effect”, we decided to select patients undergoing TKA. Two aspects of roommate similarity/dissimilarity that is particularly salient to a preoperative patient are surgical status and operative type of his or her roommate respectively. Therefore, the overarching aims of this study were to compare directly the effects of two independent angles of roommate similarity on TKA's results by assigning preoperative patients prepared to undergo TKA to a roommate whose surgical status was either similar (preoperative) or dissimilar (postoperative) and whose type of operation was either similar (TKA) or dissimilar (THA). We hypothesized that roommate’ condition affected TKA's results. 2. Methods and patients 2.1. Participants 520 eligible subjects prepared for a unilateral and primary TKA due to degenerative knee joint osteoarthritis were enrolled. As the type of anesthesia may affect outcome, only patients who received epidural anesthesia were included. The patient would be excluded if he or she had a history of knee sepsis, high tibial osteotomy, knee flexion contracture, varus/valgus deformity of greater than 20 , less than 90 degrees of knee flexion, neurological disease, mental disorder, major surgery or affective disorder. All these would produce a significant difference from their roommate. Patients unwilling to participate in this study and refusing to a double room were also excluded. 2.2. Study design We performed a randomized and controlled study comparing the effect of patients' dyads during hospitalization from October 2011 to May 2013 in Chinese PLA General Hospital, 252 Hospital of Chinese PLA and First Affiliated Hospital Sun Yat-sen University. Ethical approval from the Institutional Review Board (IRB) of these three institutions and written informed consent from participants were obtained prior to the initial assessment. Randomization codes were stored in sequentially numbered opaque envelopes that were opened before admission. 2.3. Intervention Participants were randomly allocated to accept two different preoperative assignment policies according to the roommates' surgical status (pre-op vs post-operation) and the type of operation (TKA vs THA). A patient shared a room with the same roommate
until discharge and we did not change their roommate in hospital. Each patient received the same routine preoperative preparation from the hospital staff. Meanwhile, we made each ward environment identical. Participants were asked to complete required questionnaires (see Evaluation and Outcomes). Either of epidural anesthesia or nerve block was used for surgery. All TKA and THA procedures were performed by three experienced surgical teams [Liu Yujie, He Jin-Yun and Wang Zhen-Hu]. Cruciate ligamentretaining prosthesis (Gemini, Link, Germany) or uncemented hip prosthesis (Ribbed, Link, Germany) were utilized in TKA and THA respectively. Staffs that designed the study and recorded the results were blinded to the study. Thromboprophylaxis protocol was 10 mg rivaroxaban per day. Analgesic consumption included total doses of opioid and Non-Steroidal Anti-inflammatory Drugs (NSAIDs) painkillers. 2.4. Evaluation and Outcomes 1 Physical status: Short Form Health Survey (SF-36) and Western Ontario McMaster Osteoarthritis Index (WOMAC). To document the recovery status and the benefits of TJA, we decided to use SF-36 and WOMAC questionnaire, which can comprehensively document clinical and subjective improvement after joint replacement and reveal its difference. Participants were assessed before surgery and in the six months postoperatively by one clinician blinded to group allocation. 2 Patient affiliation Participants were required to estimate the number of hours they had spent talking with their respective roommate. A patientreported questionnaire on separate 4-point scales that ranged from not at all [1] to very much so [4] was applicated to assess patient affiliation three aspects including cognitive clarity, emotional comparison, and emotional support. Those were assessed in the six months postoperatively. Relevant to cognitive clarity, patients were asked to indicate the extent to which they (a) discussed with their roommate how it would feel after TKA, (b) discussed ways to make recovery and exercise easier, (c) learned things by watching their roommate that would be helpful for their own recovery, (d) learned things by talking to their respective roommate that would be helpful for their own recovery, and (e) felt they had “a better idea of what to expect after TKA” because of their roommate. In an effort to assess emotional comparison activity, we also asked patients to indicate the extent to which they (a) mentioned to their roommate how they felt emotionally about joint replacement (e.g., how calm or nervous), (b) thought about how nervous their roommate seemed compared with themselves, and (c) were told by their roommate how he felt emotionally about his joint replacement (e.g., how calm or nervous). To assess emotional support affiliations, we asked patients to indicate the extent to which (a) their roommate said things to them in an effort to make them feel better about their TKA (e.g., “things will be all right”), (b) they said things to their roommate in an effort to make him feel better about his TKA, and (c) they liked joking with their roommate about their TKAs [12]. 3 Psychological status: preoperative anxiety and expectation Patients completed a short (10-item) form of the State version of the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, &
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
Lushene, 1970), which provides a valid measure of state anxiety. Satisfaction of patients undergoing TKA was assessed using a 100mm visual analog scale, ranging from 0 ¼ highly dissatisfied to 100 ¼ completely satisfied. Both anxiety and expectation were evaluated in the evening before surgery. 4 Analgesic consumption and length of hospital stay Analgesic consumption during early postoperative periods (two weeks after TKA) and length of hospital stay in this study was also recorded.
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2.5. Statistical methods Significance threshold was defined as 0.05, that is, P-value. The number of 120 subjects in each group was enough to detect a 20% reduction between groups with alpha 0.05 and beta 0.1. The power analysis using Power and Sample Size Calculation was calculated to be 90%. Descriptive statistics (means, standard deviations and proportions) were showed for all study variables. We evaluated the change between groups using Student t-test. All analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, Illinois, USA).
Fig. 1. Flow chart of enrolled participants.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
Table 1 Demographic characteristics and baseline information. Variables
Assignment based on surgical status
Patient characteristics Age (years) Sex (male/female) BMI (kg/m2) Preoperative data Pain at rest ROM SF-36 WOMAC Surgery Duration of surgery (min) Duration of femoral tourniquet (min) Surgical teams (Liu Yujie/He Jin-Yun/Wang Zhen-Hu)
PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
64.8 (5.3) 12/107 27.1 (3.2)
66.1 (5.9) 10/108 27.5 (3.5)
2.8 (0.8) 108.2 (11.3) 68.2 (10.2) 46.9 (11.8) 66.3 (5.8) 28.7 (4.8) 40/45/34
P value
Assignment based on type of operation
P value
KK group (n ¼ 118)
KH group (n ¼ 119)
0.08 0.84 0.36
63.6 (7.2) 13/105 28.4 (3.3)
65.1 (7.5) 14/105 29.0 (3.1)
0.12 0.98 0.15
2.9 (0.7) 110.4 (10.8) 70.2 (11.1) 48.6 (10.8)
0.31 0.13 0.15 0.25
2.6 (1.0) 110.1 (10.8) 66.5 (11.2) 47.3 (11.5)
2.7 (0.9) 108.6 (9.8) 68.2 (12.0) 48.0 (10.8)
0.42 0.26 0.26 0.63
67.2 (7.5) 29.2 (5.0) 38/43/37
0.30 0.43 0.90
65.4 (6.2) 28.8 (4.8) 39/48/31
65.8 (6.4) 27.9 (5.2) 43/39/37
0.63 0.17 0.44
Values in parentheses are SD. t-test used for all the statistical analysis.
tended to take fewer pain medications after TKA and be released from hospital more quickly (Table 4).
3. Results Finally, 480 subjects completed the trial and were analyzed according to the ‘intention-to-treat’ principle (Fig. 1). The four groups were similar in baseline characteristics (Table 1). 3.1. Physical status: SF-36 and WOMAC scores In general, there was some tendency for SF-36 and WOMAC scores to be significantly improved better when participants were assigned to a roommate whose type of surgery was similar (TKA). However, there was no significant difference between two groups dichotomized according to surgical status (Table 2). 3.2. Patient affiliation In the six months postoperatively patients preferred to stay in touch with their respective roommates who was postoperative and underwent TKA in comparison to who was preoperative and underwent THA (Table 3). More estimated number of hours patients spent talking to their roommate was recorded when they had a roommate who was postoperative and underwent TKA as well. Besides, scores of their affiliation in three aspects tended to be higher (Table 3).
4. Discussion The factor that assignment policy could affect TKA's early recovery was rarely investigated before. Our findings were quite consistent. Both the surgical status and operative type of the roommate exerted important effects on TKA's results. Specifically if patients were randomly assigned preoperatively to a roommate who was recovering from TKA (identical surgery and different surgical status), they tended to (a) have a closer affiliation reflected by three aspects (cognitive clarity, emotional comparison and emotional support) with their respective roommate, (b) be less situational anxiety, (c) have more appropriate expectation prior to their TKA, (d) take fewer pain medications after TKA, (e) be sooner released from the hospital, and (f) show better WOMAC and SF-36 scores in patients who shared a room with a patient undergoing TKA as well. Thus, preoperative patients tend to interact with a postoperative roommate undergoing TKA not THA. Possible explanations are that “roommate effect” mainly originates from characteristics of physical and psychological condition in both sides in the same ward:
3.3. Psychological status: preoperative anxiety and expectation
(a). Patients wanted access to as much information as possible through multiple channels, e.g., the Internet, consultation with doctors and communication with patients. The study conducted by Regner Baekeland indicated patients clearly emphasized the importance of interpersonal interaction with fellow patients when it came to care, support and illness information [12,13]. However, it should be stressed here that patients don't casually select a fellow patient to talk with their conditions and feelings. Interaction questionnaire's results suggested that patients before TKA were more willing to seek information about upcoming TKA from patients who had experienced that (a roommate accepted TKA
Their expectation was significantly higher when patients had a roommate who was preoperative and underwent the different surgery, THA. Prior to their surgery, patients were less anxious if they had a roommate who was postoperative rather than likewise preoperative and underwent TKA as well rather than THA (Table 4). 3.4. Analgesic consumption and length of hospital stay Those patients who preoperatively shared a room with a postoperative patient or a patient undergoing the same operation Table 2 Effects of roommate condition on SF-36 and WOMAC scores. Variables
SF-36 WOMAC
Assignment based on surgical status PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
71.3 (9.8) 40.2 (6.8)
70.5 (10.1) 41.1 (7.6)
P value
0.54 0.34
Assignment based on type of operation KK group (n ¼ 118)
KH group (n ¼ 119)
70.8 (8.9) 39.8 (5.4)
68.1 (9.5) 41.5 (6.1)
P value
0.02* 0.02*
Values in parentheses are SD. t-test used for all the statistical analysis. * means there was a statically significant difference between groups.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
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Table 3 Patient affiliation as a function of operation type and operative status of roommate. Variables
Number of patients staying in touch with their respective roommate Number of talking hours Cognitive clarity Emotional comparison Emotional support
Assignment based on surgical status PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
76
12
4.3 (2.3) 15.8 (3.1) 8.6 (2.7) 8.4 (2.6)
3.5 (2.2) 13.3 (2.9) 6.5 (2.5) 7.0 (2.4)
P value
Assignment based on type of operation
P value
KK group (n ¼ 118)
KH group (n ¼ 119)
<0.001*
72
18
<0.001*
0.007* <0.001* <0.001* <0.001*
5.2 (2.1) 16.6 (2.7) 9.4 (2.3) 10.2 (1.8)
4.3 (2.5) 10.2 (3.5) 5.8 (2.5) 6.1 (2.4)
0.003* <0.001* <0.001* <0.001*
Values in parentheses are SD. t-test used for all the statistical analysis. *means there was a statically significant difference between groups.
Table 4 Effects of roommate condition on other TKA's clinical outcomes. Variables
Assignment based on surgical status
P value
PR-PO group (n ¼ 119)
PR-PR group (n ¼ 118)
Preoperative Anxiety Expectation Pain medications consumption Length of hospital stay
21.1 (3.6) 91.3 (3.3) 190.2 (45.3) 5.5 (0.9)
25.6 (4.2) 96.2 (3.2) 205.1 (48.3) 5.9 (1.0)
<0.001* <0.001* 0.02* 0.001*
Assignment based on type of operation KK group (n ¼ 118)
KH group (n ¼ 119)
22.3 (3.2) 90.2 (2.8) 193.6 (47.3) 5.3 (0.8)
24.8 (3.6) 96.8 (3.1) 207.5 (49.8) 5.6 (1.0)
P value
<0.001* <0.001* 0.03* 0.01*
Values in parentheses are SD. t-test used for all the statistical analysis. *means there was a statically significant difference between groups.
and was postoperative). Possible explanations for that could be that people in uncertain or stressful situations will prefer to affiliate with similar others instead of dissimilar ones. (b). In this study, patients showed a significant decrease in anxiety and were released from hospital sooner when they were assigned to a roommate who was postoperative and accepted the same surgery. Possible explanations were that these patients generally knew their postoperative conditions well and more objectively, which benefited from direct communication with patients in similar conditions. Wallace reported that patients with more knowledge about surgery have fewer worries and recover faster [14]. (c). Patients generally tend to have exorbitant expectation before surgery, which may decrease satisfaction. Moderate expectation builds on learning about what's expected side effects and discomforts in advance through observation and/or interaction with a postoperative roommate than a similarly preoperative roommate and with a roommate undergoing similar surgery than different surgery. (d). As for less pain and pain medication consumption, corresponding mechanism could be set up due to powerful
encourage and support between patients. Numerous studies have demonstrated that pain was significantly associated with negative emotions [9,12]. Positive emotions helped ease anxiety and distract from the pain feelings and physical discomforts. (e). Interestingly, patients showed better WOMAC and SF-36 scores in the six months postoperatively if they had a roommate who accepted a similar arthroplasty (TKA). Duration of share the same ward in hospital was merely couples of days (Table 4). However, unexpectedly it seemed that “roommate effect” lasted six months. Our explanation was that 63.9% (76/119) of them stayed in touch with their respective roommates by phone according to patientreported results. The advantages of our study lied in its designda prospective and randomized study with a relatively large sample. This was the first study to investigate effects of assignment policy of preoperative patients on TKA's results. We evaluated TKA's results from several aspects such as length of stay in hospital, WOMAC, ShortForm 36 scores and pain-related problems. These reflected TKA's
Fig. 2. Flow chart of advised assignment.
Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016
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T. Lijia et al. / Journal of Orthopaedic Science xxx (2017) 1e6
cost-effectiveness and patients' quality of life, which were crucial parts of TKA's results. The implications of this study lies in that “roommate effect” helps reduce length of stay in hospital. It could be advisable for Medicare and patients to apply this assignment policy which reduce medical costs (Fig. 2). There were a certain limitations in our study. It was not clear how TKA's results would turn out to be for these patients who were in a ward alone or with several patients. Specifically, in countries or centers that have patients share rooms, our results of this study may be relevant; however in many settings patients occupy private rooms and do not have this roommate interaction. Besides, consecutive patients who waited for TKA were enrolled in this study. As a result, the ratio of women/men was larger than 10:1. Our conclusions could be merely used for women. Lastly, we analyzed only the effects for the TKA's results of preoperative assignment. Therefore, the present assignment policy was recommended for patients prior to TKA. Whether it was effective for patients accepting other surgery needs a pending further investigation.
5. Conclusion Sharing the ward in hospital with one patient after TKA or postoperative patient benefited recovery from TKA by improving functional scores, pain scores, anxiety and expectation. Therefore, we advise implementation of an assignment policy that patients prior to surgery should be hospitalized with a roommate whose surgical status was dissimilar (postoperative) and whose type of surgery was similar (TKA).
Competing interest None declared.
Acknowledgements We thank the patients who participated in this study and the staff involved in this work.
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Please cite this article in press as: Lijia T, et al., Relationship between patients in hospital affects recovery from total knee arthroplasty (TKA)eA prospective study, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.05.016