Shared Decision-Making in Total Hip and Knee Arthroplasty: Understanding Surgeon and Patient Perspectives Regarding When It Is Time for Surgery.

Abstract

BACKGROUND Although total hip and total knee arthroplasty are highly successful operations, the decision of whether and when to undergo surgery is highly subjective and discretionary, and specific guidelines regarding readiness for surgery remain elusive. The nature of these decisions underscores the importance of shared decision-making, which is founded on the concept that patients substantially contribute to determining their own readiness for surgery. The OPTION survey was developed as a conversation aid to facilitate shared decision-making in the context of total joint arthroplasty. METHODS The OPTION survey was created in partnership with a panel of 10 active joint replacement patients and 15 arthroplasty surgeons, using a modified Delphi methodology that employed 3 sequential meetings by each group. The survey interrogates patient and surgeon ratings of pain, activity limitation, duration of treatment, prior treatments, and quality of life; patient-rated treatment priorities, readiness for surgery, and surgeon engagement; and surgeon-graded radiographic disease. The survey was administered as an institutional review board-approved pilot during 641 patient-clinician encounters for hip or knee arthritis at 9 U.S. sites, and was independently completed by the patient and surgeon. RESULTS Patient self-assessment of readiness for surgery includes consideration of existing functional impairment, outcome priorities, realistic expectations, and personal socioeconomic circumstances. Patients most commonly ranked removal of activity limitations as their top treatment priority, while alleviation of pain and avoidance of a long recovery were also ranked highly. Mild and severe pain were associated with similar radiographic disease severity, and worsening radiographic disease was associated with increasing patient-reported readiness for surgery. Patients and surgeons agreed on symptom severity in >90% of cases. When disagreement occurred, surgeons typically underestimated patient-reported symptoms; these cases were associated with lower patient-rated surgeon engagement in shared decision-making conversations. CONCLUSIONS Shared decision-making conversations substantially contributed to the assessment of patient readiness for joint replacement surgery. When patient and surgeon assessments were not aligned, surgeons most commonly underestimated patient-perceived impairment. These observations should inform optimal surgeon-patient communications. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.