- Email: [email protected]
Total Knee Arthroplasty Communication Checklist Increases Patient Satisfaction
Accepted Manuscript TKA Communication Checklist Increases Patient Satisfaction Sylvia Gautreau, PhD, Odette N. Gould, PhD, William W. Allanach, BSc, MD, FRCSC, Andrew E. Clark, BSc, MD, FRCSC, Steven J. Massoeurs, BSc, MD, FRCSC, Michael E. Forsythe, BSc, MD, FRCSC PII:
S0883-5403(18)31160-4
DOI:
https://doi.org/10.1016/j.arth.2018.11.032
Reference:
YARTH 56928
To appear in:
The Journal of Arthroplasty
Received Date: 14 September 2018 Revised Date:
19 November 2018
Accepted Date: 21 November 2018
Please cite this article as: Gautreau S, Gould ON, Allanach WW, Clark AE, Massoeurs SJ, Forsythe ME, TKA Communication Checklist Increases Patient Satisfaction, The Journal of Arthroplasty (2018), doi: https://doi.org/10.1016/j.arth.2018.11.032. 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.
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST
TKA Communication Checklist Increases Patient Satisfaction Corresponding Author:
RI PT
Sylvia Gautreaua, PhD
SC
The Moncton Hospital, Orthopaedic Unit, Room 6620, 135 MacBeath Avenue, Moncton, New Brunswick, Canada, E1C 6Z8 [email protected]
M AN U
Odette N. Gouldb, PhD Mount Allison University [email protected] William W. Allanacha, BSc, MD, FRCSC The Moncton Hospital [email protected]
TE D
Andrew E. Clark, BSc, MD, FRCSC The Moncton Hospital [email protected]
EP
Steven J. Massoeursa, BSc, MD, FRCSC The Moncton Hospital [email protected]
a
AC C
Michael E. Forsythea, BSc, MD, FRCSC The Moncton Hospital [email protected] The Moncton Hospital, Orthopaedic Unit, Room 6620, 135 MacBeath Avenue, Moncton, New Brunswick, Canada, E1C 6Z8
b
Mount Allison University Department of Psychology 49A York Street, Sackville, New Brunswick, Canada, E4L 1C7
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 1 2 3
TKA Communication Checklist Increases Patient Satisfaction
4
Background. Satisfaction with total knee arthroplasty (TKA) is correlated with the
ABSTRACT
fulfillment of expectations. Good surgeon-patient communication impacts how expectations are
6
formed and managed. The TKA communication checklist was developed to help surgeons better
7
understand and manage patients’ post-operative expectations in order to increase satisfaction
8
with TKA.
SC
9
RI PT
5
Methods. In this prospective cohort study, mean satisfaction scores of a standard of care communication group and a checklist intervention group were compared. The duration of post-
11
operative follow-up appointments was also assessed to determine if the checklist took
12
significantly more time in practice.
13
M AN U
10
Results. Sixty patients received the checklist in TKA appointments with surgeons between six weeks to six months post-operatively and their satisfaction ratings were compared
15
with 67 patients who had received the standard of care communication. The checklist group
16
reported higher satisfaction on overall TKA satisfaction and expectations met (p = .02), care and
17
concern shown by the surgeon (p = .01), surgeons’ communication ability (p = .01), and
18
satisfaction with time spent in follow-ups (p < .001). Satisfaction with relief from pain and return
19
to function was not significant (p = .06). More time was spent in the checklist groups’ follow-
20
ups, with a mean difference of 1 minute, 51 seconds (p = .001).
EP
AC C
21
TE D
14
Conclusion. The TKA communication checklist significantly improved patients’
22
satisfaction across multiple dimensions. This has practical significance because patient
23
satisfaction is increasingly used as a key performance indicator for surgeons and health care
24
institutions alike. Increased TKA satisfaction will benefit patients, surgeons, and the health care
25
system overall.
1
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 26 27
Keywords: Total Knee Arthroplasty; Patient Satisfaction; Surgeon-Patient Communication; Patient Expectations; Checklist
AC C
EP
TE D
M AN U
SC
RI PT
28
2
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 29 30 31 32
TKA Communication Checklist Increases Patient Satisfaction Total knee replacement (TKA) is considered to be among the most clinically successful and cost-effective medical interventions yet it is consistently reported that up to 20% of TKA patients
34
are dissatisfied with their outcomes [1–3]. Satisfaction with TKA is correlated with the
35
fulfillment of patient expectations [2] and an important contribution to this outcome involves
36
quality surgeon-patient communication [4]. A tool that contributes to the quality of time-limited
37
surgeon-patient interactions would have value because it would optimize the surgeon’s role in
38
helping patients establish and manage post-operative expectations that are realistic, achievable,
39
and most importantly, patient-specific.
M AN U
SC
RI PT
33
The aim of this study was to test the intervention of a TKA communication checklist.
41
Specifically, the main research question was, “Does the use of the communication checklist by
42
the surgeon in post-TKA follow-up appointments result in significantly greater patient
43
satisfaction after six months?” The secondary research question was, “Does the use of the
44
checklist add significantly more time to routine follow-up clinic visits?”
45
Materials and methods
EP
46
TE D
40
Participants. Persons aged 45 years and older who had a primary TKA performed by the coinvestigator surgeons in a community hospital setting were recruited for this study. There were
48
two groups, the standard of care communication group (SoC), which was the control group, and
49
the communication checklist group, the intervention group. Using a two-tailed t-test (α = .05,
50
power = .80 and Cohen’s d = 0.5), the estimated sample size for acceptable power was 64
51
patients per group [5].
AC C
47
52
Materials. The study materials included an informed consent form, a patient demographic
53
questionnaire, the TKA communication checklist, and a satisfaction questionnaire. The checklist,
3
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION shown in Figures 1 and 2, is a single page communication guide developed from the analysis of
55
interviews with patients who were within six months TKA recovery. The patient interviews and
56
the subsequent development of the checklist has been described previously [6,7]. The surgeons
57
used the checklist as a guide for discussions with the intervention patients about their progress,
58
expectations, and outcomes during any appointment between six weeks up to six months post-
59
TKA. The checklist categories include pain management, medication, physiotherapy, and general
60
and within each category are four to six topics the surgeon would address with patients during
61
follow-up visits. A reference guide and suggested script is on the reverse of the checklist.
SC
The satisfaction questionnaire was adapted and extended from the Self-Administered Patient
M AN U
62
RI PT
54
Satisfaction Scale [8]. We used four items from the original scale, namely satisfaction with the
64
results of the TKA, and satisfaction with the results of the TKA for: improving pain, improving
65
ability to do house and yard work, and improving ability to do recreational activities.
66
Psychometric testing with 1,700 hip and knee patients found good convergent validity with other
67
validated pain and function scores and excellent internal consistency reliability [8]. The scale is
68
described as “a simple instrument to explore the complex relationships between patient baseline
69
pain, functioning, expectations of surgery, and satisfaction with outcome” [8] and is cited as one
70
of the few TKA satisfaction measures with published reliability and validity data [9]. For the
71
present study, an additional eight questions were added that included topics related to satisfaction
72
with expectations being met, surgeon’s communication ability, care and concern shown by the
73
surgeon, surgeon’s ability to listen, and the amount of time the surgeon spent in follow-up visits.
74
The final scale included 12 items. Because a number of items were conceptually similar, e.g.
75
three items related to care and concern by the surgeon and three items assessed satisfaction with
AC C
EP
TE D
63
4
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 76
the surgeon’s communication ability, five subscales were derived and are described in the
77
Results section.
78
A visual analog scale (VAS) was used as the measure of satisfaction. Using satisfaction with the TKA as an example, the VAS was a 100-millimeter horizontal line with completely
80
dissatisfied at one end and completely satisfied at the other end. Above the line was written:
81
“Please mark a ‘X’ on the line below that best indicates how satisfied you are with the results of
82
your knee replacement surgery”. To score each response, the same ruler was used to measure
83
from the left in millimetres to where the X had been marked on the line and that number was
84
recorded as the score out of 100. Each VAS score ranged from 0 (completely dissatisfied) to 100
85
(completely satisfied). VAS is an appropriate method of assessing patient reported outcomes[10].
SC
M AN U
86
RI PT
79
A patient information sheet was used to collect patient demographic data including: age, gender, date of birth, height and weight (to calculate BMI), other medical conditions,
88
occupation/past occupation if retired, current living situation, i.e., living with spouse/partner, or
89
other family members or friends, or alone.
91 92
Procedure. Ethics approval was obtained from the hospital’s research ethics board (REB) and from the applicable co-authors’ university affiliations.
EP
90
TE D
87
Standard of Care Group. Participants in the standard of care group (SoC) were identified from a chronologic consecutive list from the hospital’s administrative database using the
94
following criteria: patients aged 45 years and older and having had a primary TKA between six
95
and 12 months prior by the surgeons participating in the study. The SoC group had been seen by
96
the surgeons prior to the introduction of the checklist and had received the usual communication
97
from their surgeon. Potential participants in the SoC group who were between six and 12 months
98
post-TKA were mailed a survey packet consisting of four items: (1) an informed consent form;
AC C
93
5
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 99
(2) the satisfaction VAS questionnaire; (3) the patient information sheet; and (4) an addressed postage paid return envelope. For the SoC patients, recruitment continued until a minimum of 64
101
questionnaires were returned, as per the power analysis described above. The surgeries and
102
recovery periods for the SoC group occurred between May 2014 and June 2016 while the
103
checklist was being developed.
104
RI PT
100
Checklist Intervention Group. The recruitment of the required 64 checklist participants began once the requisite number of SoC questionnaires was received from each surgeon’s
106
patients in order to decrease the likelihood that surgeons would inadvertently use elements of the
107
checklist with the standard of care patients. To recruit the checklist group, potential participants
108
who met the inclusion criteria were identified from the weekly surgical lists. Because the
109
checklist was a new intervention, the hospital REB required that patients provide consent prior to
110
the use of the checklist. The first author conducted all of the informed consent meetings. A
111
signed copy of the informed consent form was provided to each participant. Most of the consent
112
meetings occurred while the patient was in hospital after their TKA but a few occurred in the
113
orthopaedic clinic at the first follow-up visit. To mitigate the possibility of a surgeon confound,
114
the recruitment of an equal number of patients per surgeon for the SoC group and the checklist
115
was attempted. The surgeries and recovery periods for the checklist group occurred between
116
September 2016 and August 2017. There were no changes to surgical or perioperative protocols
117
during the study period.
M AN U
TE D
EP
AC C
118
SC
105
At the follow-up visits (which occurred between six weeks and six months post-TKA), the
119
surgeon used the checklist with participating patients. The checklist group was aware of the
120
checklist because the surgeon had it on a clipboard and explained its purpose when it was used
121
during the follow-up visit. The surgeon checked off each relevant item as it was reviewed, made
6
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 122
notes in the space provided if needed, and signed and dated the document to confirm the
123
checklist had been used.
124
Participants in the checklist group were then mailed a survey packet after they reached six months post-TKA. The packet included the same items as the standard of care group, except an
126
ongoing consent form was included, reminding participants that they had consented to take part
127
in the study and that their continued participation was voluntary.
For all participants, data on diagnosis of osteoarthritis versus rheumatoid arthritis, whether a
SC
128
RI PT
125
TKA on the contralateral knee or a bilateral TKA was performed, complication rates, and the
130
number of follow-up visits within the first six months post-TKA were collected from the
131
electronic health record. The mean number of months from when the survey was mailed to each
132
respondent to when the completed survey was returned was also tracked.
133
M AN U
129
Duration of clinic visits. To address the question of whether the checklist increased the amount of time spent in follow-up visits, a random sampling of the duration of clinic visits
135
(recorded in minutes and seconds) was collected in order to compare how much time in general
136
the surgeons spent with their patients in post-TKA follow-ups. A minimum of 26 observations
137
per group was required for a two-tailed t-test (α = .05, power = .80 and Cohen’s d = 0.80) [5].
138
During the standard of care (control period) and the checklist intervention period the first author
139
used the stopwatch application on the Apple iPhone to time the surgeon’s visit with patients. The
140
start marker was the time the surgeon entered the clinic examination room and the end marker
141
was when the surgeon exited the room. The first author did not interact with the patients or the
142
surgeon during the timing of the clinic visits.
AC C
EP
TE D
134
143
Data analysis. Statistical analyses were conducted with SPSS version 24.0 [11]. Descriptive
144
statistics were computed for all baseline demographic, clinical, and patient-reported variables of
7
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION interest. Differences between the SoC group and the checklist group were assessed on
146
demographic variables to determine if there were any significant group differences. Counts and
147
proportions were presented for categorical variables, and means and standard deviations for
148
continuous variables. A Cronbach alpha (α) was calculated to measure the internal consistency of
149
the subscales used for the satisfaction measure. A Cronbach α between .80 and .89 is considered
150
good and between .90 to .99 is considered excellent [12].
Differences between the SoC group and the checklist group were assessed with independent
SC
151
RI PT
145
t-tests for continuous variables and chi-square tests for categorical variables. Exploratory
153
analyses were carried out on the effects of age and gender on satisfaction using two-way
154
analyses of variance. For all statistical analyses for which a p-value was calculated, p < .05 was
155
considered significant. An effect size calculator for t-test results was used [13]. The effect size
156
operational definitions for Cohen’s d are small = 0.20; medium = 0.50; and large = 0.80 (Cohen,
157
1992). For chi-square analyses, effect sizes are phi (Φ) or Cramer’s V, small = 0.10; medium =
158
0.30; and large = 0.50 [15] and are reported in the SPSS output.
TE D
159
M AN U
152
Patient occupation (if retired, occupation before retirement) reported on the patient information sheet were classified according to the International Standard Classification of
161
Occupations, 2008 [16], then further coded by the first two authors as either a physically
162
demanding occupation or a non-physically demanding occupation.
163
Results
AC C
EP
160
164
Response Rates. A total of 149 survey packages were sent to SoC patients, three were
165
returned to sender. Of the remaining 146, there were 81 returned for a response rate of 55.5%.
166
Once the checklist phase of the study had begun in the clinic follow-up visits, one surgeon
167
withdrew participation so 12 SoC patients of this surgeon who had returned surveys were
8
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 168
removed from the data set leaving 69 participants in the SoC group. Two additional patients were
169
removed from the sample upon discovery they had a previous TKA, leaving a final SoC sample
170
of 67 patients. The consenting of the checklist group began once the requisite number of SoC surveys had
RI PT
171
been received and continued until 80 checklist patients were consented. In total 74 of these
173
participants were sent survey packets after six months post-TKA. Of the six consented
174
participants who were not sent survey packets, three were from the surgeon who withdrew from
175
the study, one patient had a femur fracture on the index knee due to a fall, one was diagnosed
176
with terminal cancer, and one had not disclosed a previous TKA. Sixty-one of the 74 participants
177
returned surveys (response rate 82.4%). Upon further investigation, one respondent’s surgery
178
was a revision, an exclusion of the study, so the final sample size for the checklist group was 60.
179
Participants. Comparisons between the SoC and checklist groups showed there were no
M AN U
SC
172
significant differences in gender, BMI, number of comorbidities, occupation type, living
181
arrangement, diagnosis of osteoarthritis versus rheumatoid arthritis, a contralateral TKA within
182
six months of the index knee, bilateral TKA, complications within 30 days of surgery, the
183
number of follow-up visits within six months post-TKA, or the mean number of months between
184
when the survey was mailed to each participant and when the survey was returned. The SoC
185
group was significantly older at 70.4 years (SD 8.0) compared to the checklist group at 64.2
186
years (SD 7.4), t (125) = 4.55, p < .001, Cohen’s d = 0.80. The response rate was significantly
187
greater for the checklist group (82.4%) compared to the SoC (55.5%), χ2 (1, n = 142) = 15.59, p
188
< .001, Φ = 0.27.
189 190
AC C
EP
TE D
180
Satisfaction subscales. Five satisfaction subscales were derived from the original 12 items in the satisfaction VAS. For each scale, an average was obtained so that scores could theoretically
9
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION range from 0 to 100. A measure of scale reliability was carried out on each of the four subscales
192
with multiple items (the fifth subscale was a single item). The resulting Cronbach alphas (α)
193
were above .90, indicating excellent internal consistency, which is how closely the items are
194
related within each subscale.
RI PT
191
Table 1 shows a summary of the results of the independent t-tests. The checklist group was
196
significantly more satisfied on four of the five satisfaction measures: satisfaction/expectations;
197
surgeon’s communication ability; care and concern shown by the surgeon; and the time the
198
surgeon spent with the patient in follow-up visits. Satisfaction with the TKA for relieving pain
199
and restoring function showed no statistically significant difference between the two groups. The
200
t-test of the mean duration in minutes of clinic visits showed that the sample of timed checklist
201
visits was significantly longer than the sample of timed SoC visits by 1 minute and 51 seconds.
M AN U
202
SC
195
Exploratory Analyses. The effects of age on satisfaction were tested with an analysis of variance (ANOVA) using a binary group comprised of younger (< 67 years) and older (≥ 67
204
years) participants. The cut-off of 67 years was used because the average age of TKA patients in
205
Canada in 2014-2015 was 67 years according to the Canadian Joint Replacement Registry [17].
206
The ANOVA with age as a factor showed no significant main effect on the five satisfaction
207
measures, F values ranged from 1.12 to 3.50, p values ranged from .29 to .06 and partial eta
208
squared (ηp2) ranged from .009 to .03. The interaction effect between age and communication
209
group was not statistically significant (F values: 0.16 - 2.44; p values: .69 - .12; ηp2: .001 - .02),
210
and as reported above, the effect of group (checklist or SoC) was significant. The ANOVA for
211
the binary variable of gender also showed no significant main effect for any of the five
212
satisfaction measures (F values: 1.40 - 3.54; p values: .25 - .06; ηp2: .01 - .03), no significant
AC C
EP
TE D
203
10
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 213
interaction effects (F values: 0.68 - 2.44; p values: .41 - .12; ηp2: .006 to .01) but the effect of
214
group (checklist versus SoC) was significant.
215
Discussion This study investigated whether a TKA communication checklist could significantly increase
RI PT
216
patient satisfaction and for the most part, the hypothesis was supported. The checklist patients
218
were significantly more satisfied across four of the five dimensions surveyed although the
219
checklist did increase the duration of clinic visits by a statistically significant yet relatively short
220
period of less than two minutes. The most likely explanation for these findings is the checklist
221
facilitated a dialogue that was mutually reinforcing. The checklist topics and format may have
222
enabled patients to express their concerns and expectations more clearly, which surgeons then
223
specifically addressed, resulting in greater patient satisfaction.
M AN U
224
SC
217
Enhanced communication benefits the orthopaedic surgeon-patient relationship, which often develops from limited interactions due to the nature of this specialization [4]. Challenges to good
226
communication include external factors such as time-limited clinic follow-ups and internal
227
factors such as a surgeon’s difficulty in intuiting patients’ information needs, expectations, and
228
worries after only a few short interactions [18]. Communication issues can also result from
229
traditional training methods that focused more on surgeon’s knowledge and technical ability and
230
less on communication and empathy [19]. Yet, communication skills can be enhanced and
231
extended from existing clinical aptitudes such as curiosity and flexibility with training and
232
tools[20]. An example from the checklist, each section includes an open-ended question intended
233
to elicit additional issues or concerns regarding that particular checklist theme. This addresses a
234
frequent complaint among patients, including orthopaedic patients, that physicians do not pay
235
enough attention to what they say, a key contributor to patient dissatisfaction [24,25]. Asking
AC C
EP
TE D
225
11
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 236
about concerns or issues necessitated taking the time to listen, which may have contributed to
237
increased satisfaction. Interestingly, ratings of satisfaction with the TKA for reducing pain and restoring function
239
were not significantly different. This suggests the checklist group, unlike the SoC group, may
240
have distinguished between the more precise evaluation of pain and function at six months and
241
the rating of overall TKA satisfaction/expectations met. Perhaps the patients who discussed pain
242
and function specifically with their surgeon via the checklist were better able to put their
243
evaluations into the context of their long-term recovery because their expectations and concerns
244
had been addressed.
SC
M AN U
245
RI PT
238
The use of the checklist over multiple visits highlights the important point that the informational needs and expectations of patients are dynamic, temporal, and subject to internal
247
and external influences [21]. The checklist’s flexibility allowed surgeons to fine-tune discussions
248
to each patients’ individual circumstance and stage of recovery and this too, may have
249
contributed to better expectations management and as a result, greater satisfaction. The checklist
250
provides a framework for surgeons to systematically yet efficiently provide comprehensive
251
follow-up care, which patients may have viewed as targeted to their individual progress, issues,
252
and concerns. Furthermore, because age and gender were not related to the groups’ satisfaction
253
differences, the utility of the checklist for individualizing care is reinforced.
EP
AC C
254
TE D
246
There was, however, a slight time cost to this individualized care. Clinic follow-up visits
255
were significantly longer when the checklist was used, albeit by less than two minutes. The
256
clinical significance of the finding can be debated. Ultimately any surgeon considering using the
257
checklist has to decide for himself/herself whether a potential two-minute difference, although
258
statistically significant, is clinically relevant when patient satisfaction can be increased.
12
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 259
Limitations. The main limitation of this study is the lack of random assignment of patients to the control and intervention groups. Similar to other health care communication studies,
261
consecutive recruitment was necessary because to randomly assign participants simultaneously
262
would likely result in the checklist items leaking into the surgeons’ communication with their
263
patients [22].
RI PT
260
Second, the checklist patients were aware of the checklist as an intervention. This could
265
create a confound if it resulted in the checklist group having a more overall positive perception
266
of their surgeon. However, since greater satisfaction was reported on some but not all of the
267
satisfaction measures, social desirability bias (or a checklist halo effect) is an unlikely
268
explanation.
M AN U
SC
264
Third, future research could address whether other members of the health care team or
270
patients themselves can use the checklist rather than the surgeon. From the patient interviews
271
used to develop the checklist it was made clear that patients expect and want information directly
272
from their surgeon [7]. Communication between surgeons and patients is central to quality health
273
care and should only be delegated after careful consideration [19]. A fourth limitation is the different response rates of the checklist (82%) and the SoC (55%)
EP
274
TE D
269
groups since significant differences in response rates may indicate biased results [23]. Response
276
rates vary greatly in health care research, ranging from 16.5% to 95% in large national
277
surveys[24–26]. In the present study, it is tempting to speculate that the higher response rate in
278
the checklist group is due to these patients’ higher rates of satisfaction with their surgery and
279
their surgeons. Follow-up research with responders and non-responders could address this
280
question.
AC C
275
13
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION Finally, it is important to acknowledge that statistical significance on a patient reported
282
outcome measure does not always imply clinical significance. It can be difficult to estimate the
283
minimal change required for meaningful effects with specific instruments and patient
284
populations [10]. In this study, the checklist increased satisfaction by 8 to 10 points on a 100-
285
point scale, which is arguably noteworthy from a clinical perspective (or at the very least worthy
286
of further study).
Conclusions. The TKA communication checklist provides a systematic way for surgeons to
SC
287
RI PT
281
discuss patients’ progress and expectations for outcomes, which allows patients to better
289
establish post-operative expectations that are more realistic and individualized, leading to
290
increased satisfaction six months post-TKA. The significance of these findings is that a simple
291
communication tool can be implemented to enhance patient satisfaction without unduly
292
sacrificing the efficiencies required in our current health care system. This is important because
293
TKA rates continue to grow due to our aging and increasingly obese population.
TE D EP AC C
294
M AN U
288
14
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 295
References [1]
Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Jt Surgery, Br Vol 2007;89:893–900. doi:10.1302/0301-620X.89B7.19091.
300 301 302
[2]
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010;468:57–63. doi:10.1007/s11999-009-1119-9.
303 304 305 306
[3]
Hamilton DF, Lane J V, Gaston P, Patton JT, Macdonald D, Simpson AHRW, et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open 2013;3:1–7. doi:10.1136/bmjopen-2012002525.
307 308
[4]
Morris B, Jahangir A, Sethi M. Patient Satisfaction: An Emerging Health Policy Issue. AAOS Now 2013.
309 310 311
[5]
Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175–91.
312 313 314
[6]
Gautreau S, Aquino-Russell C, Gould ON, Forsythe ME. In their own words: A short report of patients’ experiences of recovering from total knee replacement. Musculoskeletal Care 2016. doi:10.1002/msc.1169.
315 316 317
[7]
Gautreau S, Gould ON, Aquino-Russell C, Forsythe ME. Developing a surgeon-patient communication checklist for total knee arthroplasty. Musculoskeletal Care 2018;1. doi:10.1002/msc.1372.
318 319 320
[8]
Mahomed N, Gandhi R, Daltroy L, Katz JN. The self-administered patient satisfaction scale for primary hip and knee arthroplasty. Arthritis 2011;2011:1–6. doi:10.1155/2011/591253.
321 322
[9]
Lau RL, Gandhi R, Mahomed S, Mahomed N. Patient satisfaction after total knee and hip arthroplasty. Clin Geriatr Med 2012;28:349–65. doi:10.1016/j.cger.2012.05.001.
323 324 325
[10]
Rolfson O, Bohm E, Franklin P, Lyman S, Denissen G, Dawson J, et al. Patient-reported outcome measures in arthroplasty registries. Acta Orthop 2016;87:9–23. doi:10.1080/17453674.2016.1181816.
326 327
[11]
328 329
[12]
330 331 332
[13]
Ellis PD. Effect size calculators 2009. https://www.polyu.edu.hk/mm/effectsizefaqs/calculator/calculator.html (accessed October 2, 2017).
333
[14]
Cohen J. A Power Primer. Psychol Bull 1992;112:155–9.
334
[15]
Field A. Discovering Statistics Using SPSS. 3rd ed. London: Sage Publications, Inc.;
AC C
EP
TE D
M AN U
SC
RI PT
296 297 298 299
IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 24.0. Armonk, NY: IBM Corp. 2016.
Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull 1955;52:281–302.
15
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 335
2009. [16]
International Labour Organization. International standard classification of occupations. ISCO-08 Struct Index Corresp with ISC)-88 2016. http://www.ilo.org/public/english/bureau/stat/isco/isco08/index.htm (accessed June 21, 2017).
340 341
[17]
Canadian Institute for Health Information. Hip and Knee Replacements in Canada, 2014– 2015: Canadian Joint Replacement Registry Annual Report. Ottawa, ON: 2017.
342 343 344
[18]
Levinson W, Hudak P, Tricco AC. A systematic review of surgeon-patient communication: strengths and opportunities for improvement. Patient Educ Couns 2013;93:3–17. doi:10.1016/j.pec.2013.03.023.
345 346
[19]
Tongue J, Epps H, Forese LL. Communication skills for patient-centered care. J Bone Jt Surg 2005;87:652–8.
347 348 349
[20]
Epstein RM. Making communication research matter: What do patients notice, what do patients want, and what do patients need? Patient Educ Couns 2006;60:272–8. doi:10.1016/j.pec.2005.11.003.
350 351
[21]
Thompson AG, Suñol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care 1995;7:127–41.
352 353 354
[22]
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9. doi:10.1056/NEJMsa0810119.
355 356 357
[23]
van den Akker-Scheek I, van Raay JJ a M, Reininga IHF, Bulstra SK, Zijlstra W, Stevens M. Reliability and concurrent validity of the Dutch hip and knee replacement expectations surveys. BMC Musculoskelet Disord 2010;11:242. doi:10.1186/1471-2474-11-242.
358 359 360
[24]
Tyser AR, Abtahi AM, McFadden M, Presson AP. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res 2016;16:350. doi:10.1186/s12913-016-1595-z.
361 362 363
[25]
Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: A report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand 2000;71:262–7. doi:10.1080/000164700317411852.
364 365 366
[26]
Drake KM, Hargraves JL, Lloyd S, Gallagher PM, Cleary PD. The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group Survey. Health Serv Res 2014;49:1387–99. doi:10.1111/1475-6773.12160.
368 369
SC
M AN U
TE D
EP
AC C
367
RI PT
336 337 338 339
370
16
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 371 372
Table 1
373
Summary of Independent T-tests on Satisfaction and Duration of Clinic Visits M Diff.
p
d
Time Spent in Follow-up
81.9 (23.81)
93.1 (7.24)
11.2
< .001
0.64
Surgeon Communication
83.6 (23.24)
92.0 (9.28)
8.4
.008
0.48
Surgeon Care & Concern
83.9 (22.46)
92.0 (10.05)
8.1
.011
0.46
Satisfaction-Expectations
77.2 (28.41)
87.3 (17.01)
10.1
.017
0.43
Pain & Function
77.0 (27.95)
85.3 (20.39)
8.3
.064
0.34
Duration of Visits
4:02 (2:11)
5:53 (2:38)
.001
0.76
SC
RI PT
Checklist, M (SD)
1:51
EP
TE D
M AN U
Note. SoC = standard of care. M Diff. = mean difference. d = Cohen’s d effect size (0.2 = small, 0.5 = medium, 0.8 = large). M = mean. SD = standard deviation. Significance is p < .05, indicated in bold.
AC C
374 375 376 377
SoC, M (SD)
17
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION
AC C
EP
TE D
M AN U
SC
RI PT
378
379 380 381
Figure 1 TKA Outcome Communication Checklist (front) 18
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION
AC C
EP
TE D
M AN U
SC
RI PT
382 383
384 385 386
Figure 2 TKA Outcome Communication Checklist (reverse)
19
ACCEPTED MANUSCRIPT
TKA Communication Checklist Increases Patient Satisfaction
Acknowledgements: Dr. Catherine-Aquino Russell
AC C
EP
TE D
M AN U
SC
RI PT
Funding: This work was supported by the New Brunswick Health Research Foundation [grant number 2014 AHR 733].
S0883-5403(18)31160-4
DOI:
https://doi.org/10.1016/j.arth.2018.11.032
Reference:
YARTH 56928
To appear in:
The Journal of Arthroplasty
Received Date: 14 September 2018 Revised Date:
19 November 2018
Accepted Date: 21 November 2018
Please cite this article as: Gautreau S, Gould ON, Allanach WW, Clark AE, Massoeurs SJ, Forsythe ME, TKA Communication Checklist Increases Patient Satisfaction, The Journal of Arthroplasty (2018), doi: https://doi.org/10.1016/j.arth.2018.11.032. 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.
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST
TKA Communication Checklist Increases Patient Satisfaction Corresponding Author:
RI PT
Sylvia Gautreaua, PhD
SC
The Moncton Hospital, Orthopaedic Unit, Room 6620, 135 MacBeath Avenue, Moncton, New Brunswick, Canada, E1C 6Z8 [email protected]
M AN U
Odette N. Gouldb, PhD Mount Allison University [email protected] William W. Allanacha, BSc, MD, FRCSC The Moncton Hospital [email protected]
TE D
Andrew E. Clark, BSc, MD, FRCSC The Moncton Hospital [email protected]
EP
Steven J. Massoeursa, BSc, MD, FRCSC The Moncton Hospital [email protected]
a
AC C
Michael E. Forsythea, BSc, MD, FRCSC The Moncton Hospital [email protected] The Moncton Hospital, Orthopaedic Unit, Room 6620, 135 MacBeath Avenue, Moncton, New Brunswick, Canada, E1C 6Z8
b
Mount Allison University Department of Psychology 49A York Street, Sackville, New Brunswick, Canada, E4L 1C7
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 1 2 3
TKA Communication Checklist Increases Patient Satisfaction
4
Background. Satisfaction with total knee arthroplasty (TKA) is correlated with the
ABSTRACT
fulfillment of expectations. Good surgeon-patient communication impacts how expectations are
6
formed and managed. The TKA communication checklist was developed to help surgeons better
7
understand and manage patients’ post-operative expectations in order to increase satisfaction
8
with TKA.
SC
9
RI PT
5
Methods. In this prospective cohort study, mean satisfaction scores of a standard of care communication group and a checklist intervention group were compared. The duration of post-
11
operative follow-up appointments was also assessed to determine if the checklist took
12
significantly more time in practice.
13
M AN U
10
Results. Sixty patients received the checklist in TKA appointments with surgeons between six weeks to six months post-operatively and their satisfaction ratings were compared
15
with 67 patients who had received the standard of care communication. The checklist group
16
reported higher satisfaction on overall TKA satisfaction and expectations met (p = .02), care and
17
concern shown by the surgeon (p = .01), surgeons’ communication ability (p = .01), and
18
satisfaction with time spent in follow-ups (p < .001). Satisfaction with relief from pain and return
19
to function was not significant (p = .06). More time was spent in the checklist groups’ follow-
20
ups, with a mean difference of 1 minute, 51 seconds (p = .001).
EP
AC C
21
TE D
14
Conclusion. The TKA communication checklist significantly improved patients’
22
satisfaction across multiple dimensions. This has practical significance because patient
23
satisfaction is increasingly used as a key performance indicator for surgeons and health care
24
institutions alike. Increased TKA satisfaction will benefit patients, surgeons, and the health care
25
system overall.
1
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 26 27
Keywords: Total Knee Arthroplasty; Patient Satisfaction; Surgeon-Patient Communication; Patient Expectations; Checklist
AC C
EP
TE D
M AN U
SC
RI PT
28
2
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 29 30 31 32
TKA Communication Checklist Increases Patient Satisfaction Total knee replacement (TKA) is considered to be among the most clinically successful and cost-effective medical interventions yet it is consistently reported that up to 20% of TKA patients
34
are dissatisfied with their outcomes [1–3]. Satisfaction with TKA is correlated with the
35
fulfillment of patient expectations [2] and an important contribution to this outcome involves
36
quality surgeon-patient communication [4]. A tool that contributes to the quality of time-limited
37
surgeon-patient interactions would have value because it would optimize the surgeon’s role in
38
helping patients establish and manage post-operative expectations that are realistic, achievable,
39
and most importantly, patient-specific.
M AN U
SC
RI PT
33
The aim of this study was to test the intervention of a TKA communication checklist.
41
Specifically, the main research question was, “Does the use of the communication checklist by
42
the surgeon in post-TKA follow-up appointments result in significantly greater patient
43
satisfaction after six months?” The secondary research question was, “Does the use of the
44
checklist add significantly more time to routine follow-up clinic visits?”
45
Materials and methods
EP
46
TE D
40
Participants. Persons aged 45 years and older who had a primary TKA performed by the coinvestigator surgeons in a community hospital setting were recruited for this study. There were
48
two groups, the standard of care communication group (SoC), which was the control group, and
49
the communication checklist group, the intervention group. Using a two-tailed t-test (α = .05,
50
power = .80 and Cohen’s d = 0.5), the estimated sample size for acceptable power was 64
51
patients per group [5].
AC C
47
52
Materials. The study materials included an informed consent form, a patient demographic
53
questionnaire, the TKA communication checklist, and a satisfaction questionnaire. The checklist,
3
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION shown in Figures 1 and 2, is a single page communication guide developed from the analysis of
55
interviews with patients who were within six months TKA recovery. The patient interviews and
56
the subsequent development of the checklist has been described previously [6,7]. The surgeons
57
used the checklist as a guide for discussions with the intervention patients about their progress,
58
expectations, and outcomes during any appointment between six weeks up to six months post-
59
TKA. The checklist categories include pain management, medication, physiotherapy, and general
60
and within each category are four to six topics the surgeon would address with patients during
61
follow-up visits. A reference guide and suggested script is on the reverse of the checklist.
SC
The satisfaction questionnaire was adapted and extended from the Self-Administered Patient
M AN U
62
RI PT
54
Satisfaction Scale [8]. We used four items from the original scale, namely satisfaction with the
64
results of the TKA, and satisfaction with the results of the TKA for: improving pain, improving
65
ability to do house and yard work, and improving ability to do recreational activities.
66
Psychometric testing with 1,700 hip and knee patients found good convergent validity with other
67
validated pain and function scores and excellent internal consistency reliability [8]. The scale is
68
described as “a simple instrument to explore the complex relationships between patient baseline
69
pain, functioning, expectations of surgery, and satisfaction with outcome” [8] and is cited as one
70
of the few TKA satisfaction measures with published reliability and validity data [9]. For the
71
present study, an additional eight questions were added that included topics related to satisfaction
72
with expectations being met, surgeon’s communication ability, care and concern shown by the
73
surgeon, surgeon’s ability to listen, and the amount of time the surgeon spent in follow-up visits.
74
The final scale included 12 items. Because a number of items were conceptually similar, e.g.
75
three items related to care and concern by the surgeon and three items assessed satisfaction with
AC C
EP
TE D
63
4
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 76
the surgeon’s communication ability, five subscales were derived and are described in the
77
Results section.
78
A visual analog scale (VAS) was used as the measure of satisfaction. Using satisfaction with the TKA as an example, the VAS was a 100-millimeter horizontal line with completely
80
dissatisfied at one end and completely satisfied at the other end. Above the line was written:
81
“Please mark a ‘X’ on the line below that best indicates how satisfied you are with the results of
82
your knee replacement surgery”. To score each response, the same ruler was used to measure
83
from the left in millimetres to where the X had been marked on the line and that number was
84
recorded as the score out of 100. Each VAS score ranged from 0 (completely dissatisfied) to 100
85
(completely satisfied). VAS is an appropriate method of assessing patient reported outcomes[10].
SC
M AN U
86
RI PT
79
A patient information sheet was used to collect patient demographic data including: age, gender, date of birth, height and weight (to calculate BMI), other medical conditions,
88
occupation/past occupation if retired, current living situation, i.e., living with spouse/partner, or
89
other family members or friends, or alone.
91 92
Procedure. Ethics approval was obtained from the hospital’s research ethics board (REB) and from the applicable co-authors’ university affiliations.
EP
90
TE D
87
Standard of Care Group. Participants in the standard of care group (SoC) were identified from a chronologic consecutive list from the hospital’s administrative database using the
94
following criteria: patients aged 45 years and older and having had a primary TKA between six
95
and 12 months prior by the surgeons participating in the study. The SoC group had been seen by
96
the surgeons prior to the introduction of the checklist and had received the usual communication
97
from their surgeon. Potential participants in the SoC group who were between six and 12 months
98
post-TKA were mailed a survey packet consisting of four items: (1) an informed consent form;
AC C
93
5
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 99
(2) the satisfaction VAS questionnaire; (3) the patient information sheet; and (4) an addressed postage paid return envelope. For the SoC patients, recruitment continued until a minimum of 64
101
questionnaires were returned, as per the power analysis described above. The surgeries and
102
recovery periods for the SoC group occurred between May 2014 and June 2016 while the
103
checklist was being developed.
104
RI PT
100
Checklist Intervention Group. The recruitment of the required 64 checklist participants began once the requisite number of SoC questionnaires was received from each surgeon’s
106
patients in order to decrease the likelihood that surgeons would inadvertently use elements of the
107
checklist with the standard of care patients. To recruit the checklist group, potential participants
108
who met the inclusion criteria were identified from the weekly surgical lists. Because the
109
checklist was a new intervention, the hospital REB required that patients provide consent prior to
110
the use of the checklist. The first author conducted all of the informed consent meetings. A
111
signed copy of the informed consent form was provided to each participant. Most of the consent
112
meetings occurred while the patient was in hospital after their TKA but a few occurred in the
113
orthopaedic clinic at the first follow-up visit. To mitigate the possibility of a surgeon confound,
114
the recruitment of an equal number of patients per surgeon for the SoC group and the checklist
115
was attempted. The surgeries and recovery periods for the checklist group occurred between
116
September 2016 and August 2017. There were no changes to surgical or perioperative protocols
117
during the study period.
M AN U
TE D
EP
AC C
118
SC
105
At the follow-up visits (which occurred between six weeks and six months post-TKA), the
119
surgeon used the checklist with participating patients. The checklist group was aware of the
120
checklist because the surgeon had it on a clipboard and explained its purpose when it was used
121
during the follow-up visit. The surgeon checked off each relevant item as it was reviewed, made
6
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 122
notes in the space provided if needed, and signed and dated the document to confirm the
123
checklist had been used.
124
Participants in the checklist group were then mailed a survey packet after they reached six months post-TKA. The packet included the same items as the standard of care group, except an
126
ongoing consent form was included, reminding participants that they had consented to take part
127
in the study and that their continued participation was voluntary.
For all participants, data on diagnosis of osteoarthritis versus rheumatoid arthritis, whether a
SC
128
RI PT
125
TKA on the contralateral knee or a bilateral TKA was performed, complication rates, and the
130
number of follow-up visits within the first six months post-TKA were collected from the
131
electronic health record. The mean number of months from when the survey was mailed to each
132
respondent to when the completed survey was returned was also tracked.
133
M AN U
129
Duration of clinic visits. To address the question of whether the checklist increased the amount of time spent in follow-up visits, a random sampling of the duration of clinic visits
135
(recorded in minutes and seconds) was collected in order to compare how much time in general
136
the surgeons spent with their patients in post-TKA follow-ups. A minimum of 26 observations
137
per group was required for a two-tailed t-test (α = .05, power = .80 and Cohen’s d = 0.80) [5].
138
During the standard of care (control period) and the checklist intervention period the first author
139
used the stopwatch application on the Apple iPhone to time the surgeon’s visit with patients. The
140
start marker was the time the surgeon entered the clinic examination room and the end marker
141
was when the surgeon exited the room. The first author did not interact with the patients or the
142
surgeon during the timing of the clinic visits.
AC C
EP
TE D
134
143
Data analysis. Statistical analyses were conducted with SPSS version 24.0 [11]. Descriptive
144
statistics were computed for all baseline demographic, clinical, and patient-reported variables of
7
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION interest. Differences between the SoC group and the checklist group were assessed on
146
demographic variables to determine if there were any significant group differences. Counts and
147
proportions were presented for categorical variables, and means and standard deviations for
148
continuous variables. A Cronbach alpha (α) was calculated to measure the internal consistency of
149
the subscales used for the satisfaction measure. A Cronbach α between .80 and .89 is considered
150
good and between .90 to .99 is considered excellent [12].
Differences between the SoC group and the checklist group were assessed with independent
SC
151
RI PT
145
t-tests for continuous variables and chi-square tests for categorical variables. Exploratory
153
analyses were carried out on the effects of age and gender on satisfaction using two-way
154
analyses of variance. For all statistical analyses for which a p-value was calculated, p < .05 was
155
considered significant. An effect size calculator for t-test results was used [13]. The effect size
156
operational definitions for Cohen’s d are small = 0.20; medium = 0.50; and large = 0.80 (Cohen,
157
1992). For chi-square analyses, effect sizes are phi (Φ) or Cramer’s V, small = 0.10; medium =
158
0.30; and large = 0.50 [15] and are reported in the SPSS output.
TE D
159
M AN U
152
Patient occupation (if retired, occupation before retirement) reported on the patient information sheet were classified according to the International Standard Classification of
161
Occupations, 2008 [16], then further coded by the first two authors as either a physically
162
demanding occupation or a non-physically demanding occupation.
163
Results
AC C
EP
160
164
Response Rates. A total of 149 survey packages were sent to SoC patients, three were
165
returned to sender. Of the remaining 146, there were 81 returned for a response rate of 55.5%.
166
Once the checklist phase of the study had begun in the clinic follow-up visits, one surgeon
167
withdrew participation so 12 SoC patients of this surgeon who had returned surveys were
8
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 168
removed from the data set leaving 69 participants in the SoC group. Two additional patients were
169
removed from the sample upon discovery they had a previous TKA, leaving a final SoC sample
170
of 67 patients. The consenting of the checklist group began once the requisite number of SoC surveys had
RI PT
171
been received and continued until 80 checklist patients were consented. In total 74 of these
173
participants were sent survey packets after six months post-TKA. Of the six consented
174
participants who were not sent survey packets, three were from the surgeon who withdrew from
175
the study, one patient had a femur fracture on the index knee due to a fall, one was diagnosed
176
with terminal cancer, and one had not disclosed a previous TKA. Sixty-one of the 74 participants
177
returned surveys (response rate 82.4%). Upon further investigation, one respondent’s surgery
178
was a revision, an exclusion of the study, so the final sample size for the checklist group was 60.
179
Participants. Comparisons between the SoC and checklist groups showed there were no
M AN U
SC
172
significant differences in gender, BMI, number of comorbidities, occupation type, living
181
arrangement, diagnosis of osteoarthritis versus rheumatoid arthritis, a contralateral TKA within
182
six months of the index knee, bilateral TKA, complications within 30 days of surgery, the
183
number of follow-up visits within six months post-TKA, or the mean number of months between
184
when the survey was mailed to each participant and when the survey was returned. The SoC
185
group was significantly older at 70.4 years (SD 8.0) compared to the checklist group at 64.2
186
years (SD 7.4), t (125) = 4.55, p < .001, Cohen’s d = 0.80. The response rate was significantly
187
greater for the checklist group (82.4%) compared to the SoC (55.5%), χ2 (1, n = 142) = 15.59, p
188
< .001, Φ = 0.27.
189 190
AC C
EP
TE D
180
Satisfaction subscales. Five satisfaction subscales were derived from the original 12 items in the satisfaction VAS. For each scale, an average was obtained so that scores could theoretically
9
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION range from 0 to 100. A measure of scale reliability was carried out on each of the four subscales
192
with multiple items (the fifth subscale was a single item). The resulting Cronbach alphas (α)
193
were above .90, indicating excellent internal consistency, which is how closely the items are
194
related within each subscale.
RI PT
191
Table 1 shows a summary of the results of the independent t-tests. The checklist group was
196
significantly more satisfied on four of the five satisfaction measures: satisfaction/expectations;
197
surgeon’s communication ability; care and concern shown by the surgeon; and the time the
198
surgeon spent with the patient in follow-up visits. Satisfaction with the TKA for relieving pain
199
and restoring function showed no statistically significant difference between the two groups. The
200
t-test of the mean duration in minutes of clinic visits showed that the sample of timed checklist
201
visits was significantly longer than the sample of timed SoC visits by 1 minute and 51 seconds.
M AN U
202
SC
195
Exploratory Analyses. The effects of age on satisfaction were tested with an analysis of variance (ANOVA) using a binary group comprised of younger (< 67 years) and older (≥ 67
204
years) participants. The cut-off of 67 years was used because the average age of TKA patients in
205
Canada in 2014-2015 was 67 years according to the Canadian Joint Replacement Registry [17].
206
The ANOVA with age as a factor showed no significant main effect on the five satisfaction
207
measures, F values ranged from 1.12 to 3.50, p values ranged from .29 to .06 and partial eta
208
squared (ηp2) ranged from .009 to .03. The interaction effect between age and communication
209
group was not statistically significant (F values: 0.16 - 2.44; p values: .69 - .12; ηp2: .001 - .02),
210
and as reported above, the effect of group (checklist or SoC) was significant. The ANOVA for
211
the binary variable of gender also showed no significant main effect for any of the five
212
satisfaction measures (F values: 1.40 - 3.54; p values: .25 - .06; ηp2: .01 - .03), no significant
AC C
EP
TE D
203
10
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 213
interaction effects (F values: 0.68 - 2.44; p values: .41 - .12; ηp2: .006 to .01) but the effect of
214
group (checklist versus SoC) was significant.
215
Discussion This study investigated whether a TKA communication checklist could significantly increase
RI PT
216
patient satisfaction and for the most part, the hypothesis was supported. The checklist patients
218
were significantly more satisfied across four of the five dimensions surveyed although the
219
checklist did increase the duration of clinic visits by a statistically significant yet relatively short
220
period of less than two minutes. The most likely explanation for these findings is the checklist
221
facilitated a dialogue that was mutually reinforcing. The checklist topics and format may have
222
enabled patients to express their concerns and expectations more clearly, which surgeons then
223
specifically addressed, resulting in greater patient satisfaction.
M AN U
224
SC
217
Enhanced communication benefits the orthopaedic surgeon-patient relationship, which often develops from limited interactions due to the nature of this specialization [4]. Challenges to good
226
communication include external factors such as time-limited clinic follow-ups and internal
227
factors such as a surgeon’s difficulty in intuiting patients’ information needs, expectations, and
228
worries after only a few short interactions [18]. Communication issues can also result from
229
traditional training methods that focused more on surgeon’s knowledge and technical ability and
230
less on communication and empathy [19]. Yet, communication skills can be enhanced and
231
extended from existing clinical aptitudes such as curiosity and flexibility with training and
232
tools[20]. An example from the checklist, each section includes an open-ended question intended
233
to elicit additional issues or concerns regarding that particular checklist theme. This addresses a
234
frequent complaint among patients, including orthopaedic patients, that physicians do not pay
235
enough attention to what they say, a key contributor to patient dissatisfaction [24,25]. Asking
AC C
EP
TE D
225
11
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 236
about concerns or issues necessitated taking the time to listen, which may have contributed to
237
increased satisfaction. Interestingly, ratings of satisfaction with the TKA for reducing pain and restoring function
239
were not significantly different. This suggests the checklist group, unlike the SoC group, may
240
have distinguished between the more precise evaluation of pain and function at six months and
241
the rating of overall TKA satisfaction/expectations met. Perhaps the patients who discussed pain
242
and function specifically with their surgeon via the checklist were better able to put their
243
evaluations into the context of their long-term recovery because their expectations and concerns
244
had been addressed.
SC
M AN U
245
RI PT
238
The use of the checklist over multiple visits highlights the important point that the informational needs and expectations of patients are dynamic, temporal, and subject to internal
247
and external influences [21]. The checklist’s flexibility allowed surgeons to fine-tune discussions
248
to each patients’ individual circumstance and stage of recovery and this too, may have
249
contributed to better expectations management and as a result, greater satisfaction. The checklist
250
provides a framework for surgeons to systematically yet efficiently provide comprehensive
251
follow-up care, which patients may have viewed as targeted to their individual progress, issues,
252
and concerns. Furthermore, because age and gender were not related to the groups’ satisfaction
253
differences, the utility of the checklist for individualizing care is reinforced.
EP
AC C
254
TE D
246
There was, however, a slight time cost to this individualized care. Clinic follow-up visits
255
were significantly longer when the checklist was used, albeit by less than two minutes. The
256
clinical significance of the finding can be debated. Ultimately any surgeon considering using the
257
checklist has to decide for himself/herself whether a potential two-minute difference, although
258
statistically significant, is clinically relevant when patient satisfaction can be increased.
12
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 259
Limitations. The main limitation of this study is the lack of random assignment of patients to the control and intervention groups. Similar to other health care communication studies,
261
consecutive recruitment was necessary because to randomly assign participants simultaneously
262
would likely result in the checklist items leaking into the surgeons’ communication with their
263
patients [22].
RI PT
260
Second, the checklist patients were aware of the checklist as an intervention. This could
265
create a confound if it resulted in the checklist group having a more overall positive perception
266
of their surgeon. However, since greater satisfaction was reported on some but not all of the
267
satisfaction measures, social desirability bias (or a checklist halo effect) is an unlikely
268
explanation.
M AN U
SC
264
Third, future research could address whether other members of the health care team or
270
patients themselves can use the checklist rather than the surgeon. From the patient interviews
271
used to develop the checklist it was made clear that patients expect and want information directly
272
from their surgeon [7]. Communication between surgeons and patients is central to quality health
273
care and should only be delegated after careful consideration [19]. A fourth limitation is the different response rates of the checklist (82%) and the SoC (55%)
EP
274
TE D
269
groups since significant differences in response rates may indicate biased results [23]. Response
276
rates vary greatly in health care research, ranging from 16.5% to 95% in large national
277
surveys[24–26]. In the present study, it is tempting to speculate that the higher response rate in
278
the checklist group is due to these patients’ higher rates of satisfaction with their surgery and
279
their surgeons. Follow-up research with responders and non-responders could address this
280
question.
AC C
275
13
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION Finally, it is important to acknowledge that statistical significance on a patient reported
282
outcome measure does not always imply clinical significance. It can be difficult to estimate the
283
minimal change required for meaningful effects with specific instruments and patient
284
populations [10]. In this study, the checklist increased satisfaction by 8 to 10 points on a 100-
285
point scale, which is arguably noteworthy from a clinical perspective (or at the very least worthy
286
of further study).
Conclusions. The TKA communication checklist provides a systematic way for surgeons to
SC
287
RI PT
281
discuss patients’ progress and expectations for outcomes, which allows patients to better
289
establish post-operative expectations that are more realistic and individualized, leading to
290
increased satisfaction six months post-TKA. The significance of these findings is that a simple
291
communication tool can be implemented to enhance patient satisfaction without unduly
292
sacrificing the efficiencies required in our current health care system. This is important because
293
TKA rates continue to grow due to our aging and increasingly obese population.
TE D EP AC C
294
M AN U
288
14
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 295
References [1]
Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Jt Surgery, Br Vol 2007;89:893–900. doi:10.1302/0301-620X.89B7.19091.
300 301 302
[2]
Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 2010;468:57–63. doi:10.1007/s11999-009-1119-9.
303 304 305 306
[3]
Hamilton DF, Lane J V, Gaston P, Patton JT, Macdonald D, Simpson AHRW, et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open 2013;3:1–7. doi:10.1136/bmjopen-2012002525.
307 308
[4]
Morris B, Jahangir A, Sethi M. Patient Satisfaction: An Emerging Health Policy Issue. AAOS Now 2013.
309 310 311
[5]
Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175–91.
312 313 314
[6]
Gautreau S, Aquino-Russell C, Gould ON, Forsythe ME. In their own words: A short report of patients’ experiences of recovering from total knee replacement. Musculoskeletal Care 2016. doi:10.1002/msc.1169.
315 316 317
[7]
Gautreau S, Gould ON, Aquino-Russell C, Forsythe ME. Developing a surgeon-patient communication checklist for total knee arthroplasty. Musculoskeletal Care 2018;1. doi:10.1002/msc.1372.
318 319 320
[8]
Mahomed N, Gandhi R, Daltroy L, Katz JN. The self-administered patient satisfaction scale for primary hip and knee arthroplasty. Arthritis 2011;2011:1–6. doi:10.1155/2011/591253.
321 322
[9]
Lau RL, Gandhi R, Mahomed S, Mahomed N. Patient satisfaction after total knee and hip arthroplasty. Clin Geriatr Med 2012;28:349–65. doi:10.1016/j.cger.2012.05.001.
323 324 325
[10]
Rolfson O, Bohm E, Franklin P, Lyman S, Denissen G, Dawson J, et al. Patient-reported outcome measures in arthroplasty registries. Acta Orthop 2016;87:9–23. doi:10.1080/17453674.2016.1181816.
326 327
[11]
328 329
[12]
330 331 332
[13]
Ellis PD. Effect size calculators 2009. https://www.polyu.edu.hk/mm/effectsizefaqs/calculator/calculator.html (accessed October 2, 2017).
333
[14]
Cohen J. A Power Primer. Psychol Bull 1992;112:155–9.
334
[15]
Field A. Discovering Statistics Using SPSS. 3rd ed. London: Sage Publications, Inc.;
AC C
EP
TE D
M AN U
SC
RI PT
296 297 298 299
IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 24.0. Armonk, NY: IBM Corp. 2016.
Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull 1955;52:281–302.
15
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 335
2009. [16]
International Labour Organization. International standard classification of occupations. ISCO-08 Struct Index Corresp with ISC)-88 2016. http://www.ilo.org/public/english/bureau/stat/isco/isco08/index.htm (accessed June 21, 2017).
340 341
[17]
Canadian Institute for Health Information. Hip and Knee Replacements in Canada, 2014– 2015: Canadian Joint Replacement Registry Annual Report. Ottawa, ON: 2017.
342 343 344
[18]
Levinson W, Hudak P, Tricco AC. A systematic review of surgeon-patient communication: strengths and opportunities for improvement. Patient Educ Couns 2013;93:3–17. doi:10.1016/j.pec.2013.03.023.
345 346
[19]
Tongue J, Epps H, Forese LL. Communication skills for patient-centered care. J Bone Jt Surg 2005;87:652–8.
347 348 349
[20]
Epstein RM. Making communication research matter: What do patients notice, what do patients want, and what do patients need? Patient Educ Couns 2006;60:272–8. doi:10.1016/j.pec.2005.11.003.
350 351
[21]
Thompson AG, Suñol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care 1995;7:127–41.
352 353 354
[22]
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9. doi:10.1056/NEJMsa0810119.
355 356 357
[23]
van den Akker-Scheek I, van Raay JJ a M, Reininga IHF, Bulstra SK, Zijlstra W, Stevens M. Reliability and concurrent validity of the Dutch hip and knee replacement expectations surveys. BMC Musculoskelet Disord 2010;11:242. doi:10.1186/1471-2474-11-242.
358 359 360
[24]
Tyser AR, Abtahi AM, McFadden M, Presson AP. Evidence of non-response bias in the Press-Ganey patient satisfaction survey. BMC Health Serv Res 2016;16:350. doi:10.1186/s12913-016-1595-z.
361 362 363
[25]
Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: A report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand 2000;71:262–7. doi:10.1080/000164700317411852.
364 365 366
[26]
Drake KM, Hargraves JL, Lloyd S, Gallagher PM, Cleary PD. The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group Survey. Health Serv Res 2014;49:1387–99. doi:10.1111/1475-6773.12160.
368 369
SC
M AN U
TE D
EP
AC C
367
RI PT
336 337 338 339
370
16
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION 371 372
Table 1
373
Summary of Independent T-tests on Satisfaction and Duration of Clinic Visits M Diff.
p
d
Time Spent in Follow-up
81.9 (23.81)
93.1 (7.24)
11.2
< .001
0.64
Surgeon Communication
83.6 (23.24)
92.0 (9.28)
8.4
.008
0.48
Surgeon Care & Concern
83.9 (22.46)
92.0 (10.05)
8.1
.011
0.46
Satisfaction-Expectations
77.2 (28.41)
87.3 (17.01)
10.1
.017
0.43
Pain & Function
77.0 (27.95)
85.3 (20.39)
8.3
.064
0.34
Duration of Visits
4:02 (2:11)
5:53 (2:38)
.001
0.76
SC
RI PT
Checklist, M (SD)
1:51
EP
TE D
M AN U
Note. SoC = standard of care. M Diff. = mean difference. d = Cohen’s d effect size (0.2 = small, 0.5 = medium, 0.8 = large). M = mean. SD = standard deviation. Significance is p < .05, indicated in bold.
AC C
374 375 376 377
SoC, M (SD)
17
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION
AC C
EP
TE D
M AN U
SC
RI PT
378
379 380 381
Figure 1 TKA Outcome Communication Checklist (front) 18
ACCEPTED MANUSCRIPT TKA COMMUNICATION CHECKLIST INCREASES PATIENT SATISFACTION
AC C
EP
TE D
M AN U
SC
RI PT
382 383
384 385 386
Figure 2 TKA Outcome Communication Checklist (reverse)
19
ACCEPTED MANUSCRIPT
TKA Communication Checklist Increases Patient Satisfaction
Acknowledgements: Dr. Catherine-Aquino Russell
AC C
EP
TE D
M AN U
SC
RI PT
Funding: This work was supported by the New Brunswick Health Research Foundation [grant number 2014 AHR 733].