Ghomrawi Hassan M K, Hasan Mohamed M, Schrandt Suzanne, Song Jing, Ahmed Abdalrahman G, Riddle Daniel L, Dunlop Dorothy D, Chang Rowland W
Department of Orthopaedic Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
Comprehensive Arthritis, Musculoskeletal, Bone, and Autoimmunity Center, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
Clin Orthop Relat Res. 2025 Mar 4;483(9):1718-1728. doi: 10.1097/CORR.0000000000003436.
TKA is performed only after the patient and the surgeon agree that the potential benefits of surgery outweigh potential risks. However, as many as 20% of patients are dissatisfied after TKA, suggesting that the shared decision-making process does not consistently serve our patients well. Expected outcomes are increasingly used in clinical practice, as an addendum to preoperative clinical and demographic factors, to inform this decision; however, the added value of this information in aligning patients and surgeons regarding the benefit and risk of TKA remains poorly understood.
QUESTIONS/PURPOSES: (1) How do patients' ratings of appropriateness of TKA (based on benefits and risks as appropriate, inappropriate, or inconclusive) compare with clinicians' ratings of appropriateness for 279 hypothetical patient scenarios that include both preoperative factors and expected outcomes? (2) Did expected outcomes drive the patients' ratings? (3) What additional factors, not accounted for in the hypothetical patient scenarios, also affected the patients' ratings of appropriateness of TKA for these scenarios?
TKA appropriateness ratings for 279 hypothetical patient scenarios were previously developed using the RAND/UCLA Delphi method and rated by a panel of clinicians as either inappropriate, inconclusive, or appropriate. These scenarios are composed of clinically plausible permutations of five preoperative factors and three expected postoperative outcome factors. Expected outcomes were shown to be the most important drivers of physicians' classification. In this study, a panel of eight patients (four with end-stage osteoarthritis [OA] without TKA and four who recently underwent TKA) independently rated the appropriateness of TKA for the same 279 scenarios on a scale from 1 to 9 (1 to 3 were considered inappropriate, 4 to 6 inconclusive, and 7 to 9 appropriate). These patients were identified by the Arthritis Foundation with equal representation of men and women who had TKA and those who did not and were educated on the clinical meaning and relevance of each factor. The median score rating was then classified into either "inappropriate," "inconclusive," or "appropriate," and categories were compared with those of the clinicians for the same scenarios. Classification tree (CART) analysis was applied to the patient-assessed TKA appropriateness categories to identify the most influential of the eight factors. After completing the appropriateness ratings, the same eight patients were convened in two focus groups to elucidate qualitatively any additional factors that influenced their ratings. Semistructured interviews were conducted, and qualitative methods were applied to the narrative to determine these additional factors.
Based on patients' median score for the 279 scenarios, 15% (43) of scenarios were classified as inappropriate, 53% (148) of scenarios as inconclusive, and 32% (88) of scenarios as appropriate. Overall, concordance between the patient and the surgeon classifications was 68% (weighted κ = 0.58 [95% confidence interval 0.51 to 0.66]; p < 0.001). None of the scenarios that the clinicians classified as appropriate were classified as inappropriate by the patients and vice versa. Preoperative symptom severity, OA radiographic severity, expected rate of serious complications, and expected improvement at 2 years were crucial factors that discriminated among the patient-assessed TKA appropriateness classification categories. The semistructured qualitative interviews with the same eight patients from focus groups identified risks of opioid addiction and fear of functional deterioration as additional important factors for patients to consider TKA earlier.
When expected outcomes were included as part of a clinical scenario, patients generally agreed with the clinicians when a TKA was appropriate, suggesting that expected outcomes may further increase concordance between patients and surgeons.
Incorporating expected outcomes into clinical practice and engaging patients to understand all the factors affecting their decisions may aid surgeons in guiding the shared decision-making process and ultimately reduce dissatisfaction with the outcome of surgery.
全膝关节置换术（TKA）仅在患者和外科医生一致认为手术的潜在益处超过潜在风险后才进行。然而，多达20%的患者在TKA术后不满意，这表明共同决策过程并不能始终很好地为我们的患者服务。预期结果在临床实践中越来越多地被用作术前临床和人口统计学因素的补充，以辅助这一决策；然而，这些信息在使患者和外科医生就TKA的益处和风险达成一致方面的附加价值仍知之甚少。
问题/目的：（1）在279个包含术前因素和预期结果的假设患者场景中，患者对TKA适宜性的评分（基于益处和风险，分为适宜、不适宜或不确定）与临床医生的评分相比如何？（2）预期结果是否影响患者的评分？（3）在假设患者场景中未考虑的哪些其他因素也影响了患者对这些场景中TKA适宜性的评分？
先前使用RAND/UCLA德尔菲法制定了279个假设患者场景的TKA适宜性评分，并由一组临床医生评定为不适宜、不确定或适宜。这些场景由五个术前因素和三个术后预期结果因素的临床合理组合构成。预期结果被证明是医生分类的最重要驱动因素。在本研究中，一组八名患者（四名终末期骨关节炎[OA]未行TKA的患者和四名近期接受TKA的患者）独立地对相同的279个场景的TKA适宜性进行评分，评分范围为1至9分（1至3分被认为不适宜，4至6分为不确定，7至9分为适宜）。这些患者由关节炎基金会确定，接受TKA和未接受TKA的男性和女性比例相同，并接受了关于每个因素的临床意义和相关性的教育。然后将中位数评分分类为“不适宜”、 “不确定”或“适宜”，并将这些类别与临床医生对相同场景的分类进行比较。分类树（CART）分析应用于患者评估的TKA适宜性类别，以确定八个因素中最具影响力的因素。在完成适宜性评分后，相同的八名患者被召集到两个焦点小组中，以定性地阐明影响其评分的任何其他因素。进行了半结构化访谈，并对叙述内容应用定性方法以确定这些其他因素。
根据患者对279个场景的中位数评分，15%（43个）场景被分类为不适宜，53%（148个）场景为不确定，32%（88个）场景为适宜。总体而言，患者和外科医生分类之间的一致性为68%（加权κ=0.58[95%置信区间0.51至0.66]；p<0.001）。临床医生分类为适宜的场景中，没有一个被患者分类为不适宜，反之亦然。术前症状严重程度、OA影像学严重程度、严重并发症的预期发生率以及2年时的预期改善是区分患者评估的TKA适宜性分类类别的关键因素。对来自焦点小组的相同八名患者进行的半结构化定性访谈确定，阿片类药物成瘾风险和对功能恶化的恐惧是患者更早考虑TKA的另外重要因素。
当预期结果作为临床场景的一部分纳入时，在TKA适宜的情况下患者通常与临床医生意见一致，这表明预期结果可能会进一步提高患者和外科医生之间的一致性。
将预期结果纳入临床实践并让患者了解影响其决策的所有因素，可能有助于外科医生指导共同决策过程，并最终减少对手术结果的不满。
