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Which Factors Are Considered by Patients When Considering Total Joint Arthroplasty? A Discrete-choice Experiment
Clinical Orthopaedics and Related Research ( IF 4.2 ) Pub Date : 2023-03-01 , DOI: 10.1097/corr.0000000000002358
Mehdi Sina Salimy 1 , Tyler James Humphrey 1, 2 , Akhil Katakam 1, 2 , Christopher M Melnic 1, 2 , Marilyn Heng 1 , Hany S Bedair 1, 2
Affiliation  

Background 

TKA and THA are major surgical procedures, and they are associated with the potential for serious, even life-threatening complications. Patients must weigh the risks of these complications against the benefits of surgery. However, little is known about the relative importance patients place on the potential complications of surgery compared with any potential benefit the procedures may achieve. Furthermore, patient preferences may often be discordant with surgeon preferences regarding the treatment decision-making process. A discrete-choice experiment (DCE) is a quantitative survey technique designed to elicit patient preferences by presenting patients with two or more hypothetical scenarios. Each scenario is composed of several attributes or factors, and the relative extent to which respondents prioritize these attributes can be quantified to assess preferences when making a decision, such as whether to pursue lower extremity arthroplasty.

Questions/purposes 

In this DCE, we asked: (1) Which patient-related factors (such as pain and functional level) and surgery-related factors (such as the risk of infection, revision, or death) are influential in patients’ decisions about whether to undergo lower extremity arthroplasty? (2) Which of these factors do patients emphasize the most when making this decision?

Methods 

A DCE was designed with the following attributes: pain; physical function; return to work; and infection risks, reoperation, implant failure leading to premature revision, deep vein thrombosis, and mortality. From October 2021 to March 2022, we recruited all new patients to two arthroplasty surgeons’ clinics who were older than 18 years and scheduled for a consultation for knee- or hip-related complaints who had no previous history of a primary TKA or THA. A total of 56% (292 of 517) of new patients met the inclusion criteria and were approached with the opportunity to complete the DCE. Among the cohort, 51% (150 of 292) of patients completed the DCE. Patients were administered the DCE, which consisted of 10 hypothetical scenarios that had the patient decide between a surgical and nonsurgical outcome, each consisting of varying levels of eight attributes (such as infection, reoperation, and ability to return to work). A subsequent demographic questionnaire followed this assessment. To answer our first research question about the patient-related and surgery-related factors that most influence patients’ decisions to undergo lower extremity arthroplasty, we used a conditional logit regression to control for potentially confounding attributes from within the DCE and determine which variables shifted a patient’s determination to pursue surgery. To answer our second question, about which of these factors received the greatest priority by patients, we compared the relevant importance of each factor, as determined by each factor’s beta coefficient, against each other influential factor. A larger absolute value of beta coefficient reflects a relatively higher degree of importance placed on a variable compared with other variables within our study. Of the respondents, 57% (85 of 150) were women, and the mean age at the time of participation was 64 ± 10 years. Most respondents (95% [143 of 150]) were White. Regarding surgery, 38% (57 of 150) were considering THA, 59% (88 of 150) were considering TKA, and 3% (5 of 150) were considering both. Among the cohort, 49% (74 of 150) of patients reported their average pain level as severe, or 7 to 10 on a scale from 0 to 10, and 47% (71 of 150) reported having 50% of full physical function.

Results 

Variables that were influential to respondents when deciding on lower extremity total joint arthroplasty were improvement from severe pain to minimal pain (β coefficient: -0.59 [95% CI -0.72 to -0.46]; p < 0.01), improvement in physical function level from 50% to 100% (β: -0.80 [95% CI -0.9 to -0.7]; p < 0.01), ability to return to work versus inability to return (β: -0.38 [95% CI -0.48 to -0.28]; p < 0.01), and the surgery-related factor of risk of infection (β: -0.22 [95% CI -0.30 to -0.14]; p < 0.01). Improvement in physical function from 50% to 100% was the most important for patients making this decision because it had the largest absolute coefficient value of -0.80. To improve physical function from 50% to 100% and reduce pain from severe to minimal because of total joint arthroplasty, patients were willing to accept a hypothetical absolute (and not merely an incrementally increased) 37% and 27% risk of infection, respectively. When we stratified our analysis by respondents’ preoperative pain levels, we identified that only patients with severe pain at the time of their appointment found the risk of infection influential in their decision-making process (β: -0.27 [95% CI -0.37 to -0.17]; p = 0.01) and were willing to accept a 24% risk of infection to improve their physical functioning from 50% to 100%.

Conclusion 

Our study revealed that patients consider pain alleviation, physical function improvement, and infection risk to be the most important attributes when considering total joint arthroplasty. Patients with severe baseline pain demonstrated a willingness to take on a hypothetically high infection risk as a tradeoff for improved physical function or pain relief. Because patients seemed to prioritize postoperative physical function so highly in our study, it is especially important that surgeons customize their presentations about the likelihood an individual patient will achieve a substantial functional improvement as part of any office visit where arthroplasty is discussed. Future studies should focus on quantitatively assessing patients’ understanding of surgical risks after a surgical consultation, especially in patients who may be the most risk tolerant.

Clinical Relevance 

Surgeons should be aware that patients with the most limited physical function and the highest baseline pain levels are more willing to accept the more potentially life-threatening and devastating risks that accompany total joint arthroplasty, specifically infection. The degree to which patients seemed to undervalue the harms of infection (based on our knowledge and perception of those harms) suggests that surgeons need to take particular care in explaining the degree to which a prosthetic joint infection can harm or kill patients who develop one.



中文翻译:

患者在考虑全关节置换术时会考虑哪些因素?离散选择实验

背景 

TKA 和 THA 是主要的外科手术,它们可能会导致严重甚至危及生命的并发症。患者必须权衡这些并发症的风险与手术的益处。然而,与手术可能实现的潜在益处相比,患者对手术潜在并发症的相对重要性知之甚少。此外,患者的偏好常常可能与外科医生在治疗决策过程中的偏好不一致。离散选择实验 (DCE) 是一种定量调查技术,旨在通过向患者呈现两个或多个假设场景来引发患者偏好。每个场景由多个属性或因素组成,

问题/目的 

在本次 DCE 中,我们询问:(1)哪些患者相关因素(例如疼痛和功能水平)和手术相关因素(例如感染、翻修或死亡的风险)会影响患者是否接受手术的决定。接受下肢关节置换术吗?(2) 患者在做出这个决定时最看重哪些因素?

方法 

DCE 的设计具有以下属性: 疼痛;身体机能;重返工作岗位; 感染风险、再次手术、导致过早翻修的植入失败、深静脉血栓形成和死亡。从 2021 年 10 月到 2022 年 3 月,我们招募了两家关节置换外科医生诊所的所有新患者,这些患者年龄超过 18 岁,并计划就膝关节或髋关节相关疾病进行咨询,并且既往没有初次 TKA 或 THA 病史。总共 56%(517 名中的 292 名)新患者符合纳入标准,并有机会完成 DCE。在队列中,51%(292 名患者中的 150 名)完成了 DCE。患者接受了 DCE,其中包括 10 个假设场景,让患者在手术和非手术结果之间做出决定,每个属性由不同级别的八个属性组成(例如感染、再次手术和重返工作岗位的能力)。随后进行了人口统计调查问卷的评估。为了回答我们的第一个研究问题,即最影响患者接受下肢关节置换术的决定的患者相关因素和手术相关因素,我们使用条件 Logit 回归来控制 DCE 中潜在的混杂属性,并确定哪些变量发生了变化。患者进行手术的决心。为了回答我们的第二个问题,即患者最优先考虑哪些因素,我们将每个因素的相关重要性(由每个因素的贝塔系数确定)与其他影响因素进行了比较。β系数的绝对值越大,反映出与我们研究中的其他变量相比,该变量的重要性相对较高。在受访者中,57%(150 人中的 85 人)是女性,参与时的平均年龄为 64 ± 10 岁。大多数受访者(95% [150 人中的 143 人])是白人。关于手术,38%(150 人中的 57 人)考虑进行 THA,59%(150 人中的 88 人)考虑进行 TKA,3%(150 人中的 5 人)同时考虑两者。在该队列中,49%(150 名患者中的 74 名)报告其平均疼痛程度为严重,即 7 至 10 级(从 0 到 10 的等级),47%(150 名患者中的 71 名)报告其身体功能只有 50%。参与时的平均年龄为 64 ± 10 岁。大多数受访者(95% [150 人中的 143 人])是白人。关于手术,38%(150 人中的 57 人)考虑进行 THA,59%(150 人中的 88 人)考虑进行 TKA,3%(150 人中的 5 人)同时考虑两者。在该队列中,49%(150 名患者中的 74 名)报告其平均疼痛程度为严重,即 7 至 10 级(从 0 到 10 的等级),47%(150 名患者中的 71 名)报告其身体功能只有 50%。参与时的平均年龄为 64 ± 10 岁。大多数受访者(95% [150 人中的 143 人])是白人。关于手术,38%(150 人中的 57 人)考虑进行 THA,59%(150 人中的 88 人)考虑进行 TKA,3%(150 人中的 5 人)同时考虑两者。在该队列中,49%(150 名患者中的 74 名)报告其平均疼痛程度为严重,即 7 至 10 级(从 0 到 10 的等级),47%(150 名患者中的 71 名)报告其身体功能只有 50%。

结果 

在决定是否进行下肢全关节置换术时,对受访者有影响的变量包括从剧烈疼痛到轻微疼痛的改善(β系数:-0.59 [95% CI -0.72 至 -0.46];p < 0.01)、身体功能水平的改善50% 至 100%(β:-0.80 [95% CI -0.9 至 -0.7];p < 0.01),能够返回工作岗位与无法返回工作岗位(β:-0.38 [95% CI -0.48 至 -0.28]) ;p < 0.01),以及手术相关的感染风险因素(β:-0.22 [95% CI -0.30 至 -0.14];p < 0.01)。身体功能从 50% 改善到 100% 对于做出此决定的患者来说是最重要的,因为它的绝对系数值最大为 -0.80。由于全关节置换术,身体功能从 50% 改善到 100%,疼痛从严重减轻到轻微,患者愿意接受假设的绝对感染风险(而不仅仅是逐渐增加)分别为 37% 和 27%。当我们根据受访者的术前疼痛水平进行分层分析时,我们发现只有在就诊时疼痛严重的患者才会发现感染风险对其决策过程有影响(β:-0.27 [95% CI -0.37 至-0.17];p = 0.01)并愿意接受 24% 的感染风险,以将其身体机能从 50% 提高到 100%。-0.27 [95% CI -0.37 至 -0.17];p = 0.01)并愿意接受 24% 的感染风险,以将其身体机能从 50% 提高到 100%。-0.27 [95% CI -0.37 至 -0.17];p = 0.01)并愿意接受 24% 的感染风险,以将其身体机能从 50% 提高到 100%。

结论 

我们的研究表明,患者在考虑全关节置换术时认为缓解疼痛、改善身体功能和感染风险是最重要的因素。患有严重基线疼痛的患者表现出愿意承担假设的高感染风险,作为改善身体功能或缓解疼痛的权衡。由于在我们的研究中,患者似乎非常重视术后的身体功能,因此外科医生在讨论关节置换术的任何办公室就诊时,定制有关患者实现实质性功能改善的可能性的演示就显得尤为重要。未来的研究应侧重于定量评估患者在手术会诊后对手术风险的了解,

临床相关性 

外科医生应该意识到,身体功能最有限和基线疼痛水平最高的患者更愿意接受全关节置换术带来的潜在威胁生命和破坏性的风险,特别是感染。患者似乎低估感染危害的程度(基于我们对这些危害的了解和看法)表明,外科医生在解释假体关节感染对患者造成伤害或死亡的程度时需要特别小心。

更新日期:2023-02-23
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