Factors Influencing Patient Satisfaction With Care and Surgical Outcomes for Total Hip and Knee Replacement



 

Margaret C Wang, PhD, MPH1,2; Priscilla H Chan, MS3; Elizabeth W Paxton, MA, PhD3; Jim Bellows, PhD1; Kate Koplan, MD, MPH4; Violeta Rabrenovich, MHA5; Jeff Convissar, MD5; Nithin C Reddy, MD6; Christopher D Grimsrud, MD, PhD7; Ronald A Navarro, MD8

Perm J 2021;25:21.043

https://doi.org/10.7812/TPP/21.043

E-pub: 11/03/2021

ABSTRACT

Introduction: Although patient satisfaction with total joint arthroplasty has been a well-measured outcome, little is known about how preadmission and post-discharge care experiences affect patients’ rating of satisfaction.

Objective: This work aimed to identify actionable factors associated with better ratings of overall care and surgical results.

Methods: A 36-item survey assessing care in the preoperative, perioperative, and post-discharge phases of care and across all phases was mailed to 7,031 patients who underwent primary unilateral elective total hip arthroplasty and total knee arthroplasty in 2018. Exploratory factor analysis identified 7 actionable domains. Stepwise logistic regression models identified domains associated with ratings of overall care and satisfaction with surgical outcome.

Results: Of the 3,026 (43%) patients who returned the survey; 2,814 (93%) rated their overall experience of care as very good or excellent and satisfaction with surgical results as ≥ 7 on a 10-point scale. In exploratory factor analysis, four factors predicted higher ratings of both overall care and surgical outcome: knowing what to do with symptoms and pain during recovery (factor 1), self-reported health (factor 3), knowing what to expect before surgery (factor 4), and shared decision making (factor 6). Coordinated information among providers (factor 2), home health experience (factor 5), and patient-provider relationships (factor 7) also predicted overall care ratings.

Conclusion: Patient-centered quality improvement in total joint replacement care requires thinking of care across the entire episode, including before and after the hospital stay for surgery, in addition to perioperative care. The actionable factors identified from this study can be incorporated into total joint replacement care to improve patients’ satisfaction with overall care and surgical results.

INTRODUCTION

Joint replacement is one of the most common elective surgical procedures in the US, with more than a million hip and knee arthroplasties performed each year.1 The vast majority of knee and hip replacements are performed to reduce pain and improve mobility among patients with osteoarthritis. Yet the proportion of patients who are dissatisfied after surgery is approximately 20% for total knee arthroplasty (TKA) and 10% for total hip arthroplasty (THA).2–5

Patient satisfaction with total joint replacement care is an essential quality measure and part of the quadruple aim of improving population health, decreasing costs, and enhancing patient and provider experiences.6 Prior studies have provided insights on factors associated with patient satisfaction with total joint arthroplasty, such as patient expectations and pain management; patient’s age, sex, comorbidities, and perioperative experience; and technical aspects of total joint arthroplasty, including types of implants used.4,7,8 Currently, patient satisfaction is routinely assessed in the US with the Hospital Consumer Assessment of Healthcare Providers and Services survey. The Centers for Medicare and Medicaid Services bases reimbursement for an episode of total joint replacement care (defined as index hospitalization through 90 post-discharge days) on hospital total performance scores that include HCAHPS survey results.9,10

However, HCAHPS assesses only perioperative care, and a singular focus on these scores may overlook quality improvement opportunities occurring outside the perioperative period. For example, preoperative education and post-discharge rehabilitation are critical components of successful total joint replacement not measured by HCAHPS. Rather, improvement opportunities beyond the HCAHPS perioperative setting should be identified using an expanded timeframe including the period that begins with time of referral for surgical consultation through recovery after discharge. We refer to this period as the entire episode of care to distinguish it from the more restrictive Centers for Medicare and Medicaid Services definition.11 More importantly, despite published literature on determinants of patient satisfaction with total joint arthroplasty, there is a dearth of knowledge on predictors that are actionable to improving patient satisfaction.

To the best of our knowledge, no study has assessed patient-reported experiences and identified actionable predictors of patient satisfaction across the entire episode of care for THA and TKA. We administered a patient satisfaction survey inclusive of the entire episode of care for THA and TKA and sought to explore actionable factors associated with better ratings of overall care and surgical outcomes.

MATERIALS AND METHODS

Setting and Population

We developed and administered an episode of care survey in 6 regions of Kaiser Permanente, including Northern California, Southern California, Colorado, Northwest, Georgia, and Washington. Kaiser Permanente is one of the largest integrated healthcare organizations in the US, serving over 12 million members. All patients discharged after THA or TKA surgery in June through August of 2018 in the 6 participating regions comprised the study sample.

Kaiser Permanente launched a National Total Joint Replacement Initiative in 2016 to drive high performance in patient and physician experience, quality, and affordability of orthopedic care by supporting the spread of best practices in same-day discharge across all regions.12 Eligible orthopedic patients receiving a primary, unilateral TKA or THA can recover at home without an overnight inpatient admission. To implement the shift to same-day discharge, a multidisciplinary team led by physicians identified existing best practices. Regions aligned orthopedic practices with a playbook that included multidisciplinary team oversight, a designated total joint case manager providing a single point of contact for patients across the entire episode of care, optimized scheduling practices, and service agreements between orthopedic surgery and hospital-based physicians for patients with overnight stays. Care pathways include preoperative education and optimizing comorbidities, an early recovery after surgery bundle (ie, implementation of enhanced recovery after surgery, additional protocols, pain, blood, infection prevention, deep vein thrombosis prophylaxis, physical therapy/occupational therapy clear for discharge with criteria), an optimized postoperative pain management protocol, home nursing and physical therapy visits, and outpatient physical therapy. Effectiveness of the initiative is assessed by metrics addressing safety and quality, patient and provider satisfaction, and efficiency.12 We used multiple methods to measure patient satisfaction, including the survey reported here.

Survey Development and Administration

Because there was no existing survey instrument to enable us to assess patient satisfaction across an entire episode of care for TKA and THA, we collaborated closely with key stakeholders to develop a 36-item survey. These key stakeholders included initiative leaders, regional chiefs of orthopedic surgery, clinical and operational leaders, and patients who had recently undergone TKA or THA. Stakeholders identified important and potentially actionable domains of inquiry during the preoperative, perioperative, and postoperative phases and the overall care experience.

We then reviewed existing survey instruments and consulted with external experts to identify, adapt, and map items from validated instruments onto these domains, including measures of patient-reported health, quality of life, functional status, and pain and demographics (race/ethnicity and education). The survey (Supplemental Data File) included items applicable and generalizable across all episode-based procedures, items specific to total joint replacement, and items from the Patient-Reported Outcomes Measurement Information System13 and collaboRATE, a succinct measure of shared decision making.14,15

After developing the survey, we conducted in-depth cognitive testing with 10 and 15 patients who had respectively undergone TKA or THA in the previous 6 months, interviewing them in-depth about item relevance, literacy level, length, and response burden of the survey and accompanying cover letter.

An external survey research firm was contracted with to administer the survey. Accompanied by a cover letter, it was mailed to 7,033 patients in a single wave. Nonrespondents received up to 10 reminder phone calls 2 weeks after survey mailing. This quality improvement study did not meet criteria for institutional review board oversight.

Data Sources

In addition to the survey, an organization-wide total joint replacement registry was the second data source for the study. This registry was established in 2001 to determine clinical best practices, evaluate patient risk factors, assess clinical effectiveness of implants, and provide a foundation for research.16 Briefly, this surveillance tool for all THA and TKA procedures performed within the healthcare organization collects patient, procedure, implant, surgeon, and hospital information using electronic intraoperative forms that operating surgeons complete at the point of care. Participation to the registry is voluntary, but 95% of orthopedic surgeons performing THAs and TKAs in our organization participate. This information is supplemented with data from the electronic health records, administrative claims data, membership data, and mortality records.17

Covariates

In addition to survey responses, data on explanatory variables obtained from the joint registry included age, sex, body mass index (BMI), presence of Elixhauser comorbidities, procedure type (THA vs TKA), length of stay, discharge disposition, 30-day readmissions and emergency department utilization, and 90-day complications (deep vein thrombosis and pulmonary embolism). Educational level was estimated from respondents’ mailing addresses and census block data.

Outcome Measures

There were two outcome measures of interest in our study. The first outcome measure was patient ratings of overall care on a 5-point scale from 1 (poor) to 5 (excellent). The second outcome measure was patient ratings of satisfaction with the outcome of joint replacement surgery on a 10-point scale from 0 (not satisfied at all) to 10 (extremely satisfied). We focused on overall care ratings of “very good” and “excellent” and defined satisfaction with surgical outcome as ratings of ≥ 7 on the 10-point scale.

Statistical Analysis

We assessed differences in characteristics of respondents and nonrespondents with the χ-square test and characterized response patterns with descriptive statistics. We also used χ2 tests to examine differences among patients who were highly satisfied vs those who were not.

To identify potentially actionable domains within the large number of survey items, we conducted exploratory factor analysis using promax rotation due to correlation between items, including factors with a loading score > 0.05 and inter-item correlations ≥ 0.75. We then included these factors in separate stepwise logistic regression modeling to predict overall care ratings of excellent or very good and surgical outcome satisfaction ratings ≥ 7. Regression modeling was adjusted for independent variables that were associated with care and satisfaction ratings in univariate analyses: age, sex, annual household income, 30-day readmission, 30-day emergency department visit, length of stay, BMI, procedure (knee vs hip), osteoarthritis, comorbidities (solid tumor without metastasis, obesity, drug abuse, depression, hypertension). All tests were 2-sided with a significance threshold of 0.05; analyses were performed in R version 3.3.0.

RESULTS

The survey was mailed to 7,031 patients, and 3,026 (43.0%) patients returned it. Respondents and nonrespondents differed in systematic ways (Supplemental Table). Respondents were more likely to be older, white, have more education, a lower BMI, and fewer 30-day readmissions.

Of the 3,026 respondents, 2,814 (93%) rated their overall experience of care as “very good” or “excellent,” and 2,816 (93%) were satisfied with the results of surgery. Patients reporting overall care experience as “very good” or “excellent” were more likely to be male and had shorter length of stay after the surgery and fewer 30-day readmissions and emergency department visits (Table 1). Complete data were available for 2,116 and were included in subsequent analyses.

Table 2 presents factors, items, and inter-item correlations. Factor analysis identified 7 factors representing actionable domains associated with higher ratings of care and satisfaction with surgical results: 1) knowing what to do with symptoms and pain during recovery; 2) coordinated information among providers throughout the episode; 3) self-reported health; 4) knowing what to expect before surgery; 5) home health experience; 6) shared decision making; and 7) patient-provider relationships. All factors were significant at p < 0.05 in the model predicting overall care ratings of very good or excellent (Table 3). Four factors were significant at p < 0.05 in the model predicting surgical outcome ratings ≥ 7 (Table 4). Regression coefficients in both models ranged from 0.12 to 0.53.

DISCUSSION

Using patient-reported measures spanning the entire episode of care, we found that 4 factors associated with higher ratings of both overall care and surgical results: knowing what to expect before surgery, knowing what to do with symptoms and pain during recovery, shared decision making, and self-reported health. Coordinated information among providers throughout the care episode and home health experience also predicted overall care ratings.

Our national total joint initiative includes strategies closely related to some factors we found to be associated with care ratings of very good or excellent. Health status is a criterion for optimal patient selection for same-day discharge after TKA or THA. Robust preoperative education programs help patients and family members know what to anticipate after surgery and specifically address home pharmacologic and nonpharmacologic pain control strategies. Reliable home health rehabilitation services support patients after same-day discharge. Thus, with more than 50% of our patient population going home the day of surgery, it is not surprising that factors representing these strategies were associated with care ratings of very good or excellent, and that length of stay was inversely related to ratings of overall care.12 Analyses of verbatim comments from unsatisfied patients revealed that non-satisfaction was due to slower than expected recovery and issues related to pain management and physical therapy (data not shown).

Table 1. Characteristics of highly-satisfied and non–highly-satisfied patients

 

Highly-satisfied patients (N = 2,781)

Non–highly-satisfied patients (N = 199)

Mean age, years

69.95

68.63

Sex,a n (%)

 

 

 

Female

1,641 (61.8)

127 (70.5)

 

Male

1,011 (38.2)

53 (29.5)

Education, n (%)

 

 

 

No high school

59 (2.2)

0 (0.0)

 

Some high school

78 (2.9)

7 (3.6)

 

High school graduate

457 (16.9)

36 (18.5)

 

Some college or Associate degree

951 (35.1)

66 (33.8)

 

Bachelor’s degree

429 (15.8)

32 (16.4)

 

Graduate or professional degree

737 (27.2)

54 (27.7)

Procedure type, n (%)

 

 

 

THA

1061 (38.2)

65 (32.7)

 

TKA

1720 (61.8)

134 (67.3)

Length of stay, days past midnight,a n (%)

 

 

 

0

1263 (45.4)

68 (34.2)

 

1

1226 (44.1)

99 (49.7)

 

2

204 (7.3)

19 (9.5)

 

3+

88 (3.2)

13 (6.5)

DxCG Concurrent Scorea

1.383

1.766

30-day utilization, n (%)

 

 

 

Readmissiona

35 (1.3)

9 (4.5)

 

Emergency department visita

219 (7.9)

26 (13.1)

aDenotes statistical significance at p < 0.05.

DxCG = ; THA = total hip arthroplasty; TKA = total knee arthroplasty.

Missing values: sex N = 148, education = 74, DxCG Concurrent Score = 155.

“Highly satisfied” is defined as response “excellent” or “very good” to the question “Overall, how would you describe the care you received from Kaiser Permanente for your total knee/hip replacement surgery?” “Non-highly satisfied” is defined as response “good,” “fair,” or “poor” to the same question.

A well-documented relationship exists between patient expectations and patient satisfaction after total joint arthroplasty.4,18–20 Unrealistically high expectations can lead to frustration for patients, and low expectations may hinder rehabilitation.4,19,21 Similarly, patients who report poor pain management after TKA are more likely to be dissatisfied, as are those who report poor general health.2,18,20,22

Shared decision making is essential in preference-based healthcare decisions, including the choice to undergo elective TKA or THA.23 However, to the best of our knowledge, ours is the first study to assess the relationship between shared decision making and patient satisfaction with care and surgical outcomes. Similarly, we were unable to locate any reports of home health experience or coordination of information across providers as a predictor of satisfaction with care and outcomes in total joint arthroplasty. However, information exchange among providers is both expected by surgical patients and a key aspect of care coordination,24 which is associated with patient satisfaction.25 Positive patient-provider relationships are also associated with increased patient satisfaction.26

Strengths of our study include our assessment of care processes throughout the entire episode of care, the large survey population conducted as a census, and our response rate. Although clinical studies generally have higher response rates than ours, the 43% response rate we observed compares favorably to reported HCAHPS response rates of 27%.27 In addition, the order of questions in the survey was tested during cognitive testing to ensure optimal recall while minimizing potential bias. Several limitations deserve mention. First, systematic differences in characteristics of respondents and nonrespondents may have influenced our findings. Respondents were older, white, slightly more educated, had a lower BMI, and had fewer readmissions. Among these, fewer readmissions could have biased care experience and satisfaction ratings slightly more favorably among the respondents, as readmission is a well-known source of dissatisfaction after surgery.2,4 However, given the small

Table 2. Actionable domains identified in factor analysis

Domain

Inter-item correlationa

Loadingsb

1. Knowing what to do with symptoms and pain during recovery

0.75

 

 

Q12. Doctor and staff gave information about what to do if I had pain as a result of my surgery

 

0.560

 

Q13. I knew who to call with my symptoms and concerns

 

0.794

2. Coordinated information among providers throughout episode

0.88

 

 

Q15a. The different doctors and other staff were informed and up to date on my care or treatment

 

0.598

 

Q15b. The different doctors and other staff were consistent in the information they provided to me

 

0.915

3. Patient’s self-reported health

0.76

 

 

Q30. Very good or excellent health

 

0.751

 

Q31. Very good or excellent quality of life

 

0.834

4. Knowing what to expect before surgery

0.82

 

 

Q6. I knew the expected outcome and recovery from my total joint replacement surgery

 

0.621

 

Q7. My doctors and other staff talked with me about having the help I would need from family, friends, or paid caregivers during my recovery

 

0.885

 

Q8. My doctors and other staff gave me easy to understand instructions about getting ready for my joint replacement surgery

 

0.822

5. Home health experience

0.86

 

 

Q24. After my surgery, I had my first visit at home with the healthcare provider as soon as I wanted

 

0.719

 

Q25. Excellent or very good healthcare received at home

 

1.027

6. Shared decision making

0.95

 

 

Q18. Doctors and other staff made an effort to help me understand the condition of my joint while I was deciding whether to have total joint replacement surgery

 

0.843

 

Q19. Doctors and other staff made an effort to listen to the things that matter most to me when I was deciding whether to have total joint replacement surgery

 

1.008

 

Q20. Doctors and other staff made an effort to include what matters most to me in deciding whether to have total joint replacement surgery

 

0.937

7. Patient-provider relationships

0.99

 

 

Q15c. My appointments were scheduled without much delay

 

0.641

 

Q15d. I knew who to ask if I had a question about my total joint replacement surgery

 

0.752

 

Q15e. I was able to discuss my worries or concerns about my total joint replacement surgery with my surgeon or other staff.

 

0.726

 

Q15f. I had confidence in the surgeon who operated on me

 

0.940

 

Q15g. I had confidence in the other medical staff who took care of me when I had my total joint replacement surgery

 

0.831

aInter-item correlation, also known as Cronbach’s α, is a measure of internal consistency, in other words how closely related a set of items are as a group.

bLoading score illustrates the relative importance of the item in a domain.

Table 3. Regression coefficients and between-groups mean score differences for factors predicting overall care rating

 

 

Very good/excellent care

Good/fair/poor care

Factor

Regressiona coefficient

Mean (SD)

Mean (SD)

1. Knowing what to do with symptoms and pain during recovery

0.52

7.3 (1.1)

5.4 (1.5)

2. Coordinated information among providers throughout episode

0.26

7.0 (1.6)

4.6 (2.0)

3. Self-reported health

0.21

7.5 (1.6)

6.3 (1.5)

4. Knowing what to expect before surgery

0.19

11.0 (1.4)

8.8 (2.2)

5. Home health experience

0.18

7.9 (2.0)

5.9 (2.4)

6. Shared decision making

0.12

25.4 (3.5)

18.7 (6.9)

7. Patient-provider relationships

0.08

18.2 (3.0)

14.0 (2.9)

aRegression model adjusted for age, sex, annual household income, highest education attainment, 30-day readmission, 30-day emergency department visit, same-day length of stay, BMI, procedure (knee vs hip), osteoarthritis, comorbidities (solid tumor without metastasis, obesity, drug abuse, depression, hypertension).

Table 4. Regression coefficients and between-group mean score differences for factors predicting surgical outcome rating

 

 

Surgical outcome rating ≥ 7

Surgical outcome rating < 7

Factor

Regressiona coefficient

Mean (SD)

Mean (SD)

4. Knowing what to expect before surgery

0.28

11.0 (1.4)

9.0 (2.2)

3. Self-reported health

0.27

7.5 (1.6)

6.4 (1.7)

1. Knowing what to do with symptoms and pain during recovery

0.25

7.3 (1.1)

5.9 (1.7)

6. Shared decision making

0.12

25.4 (3.5)

19.6 (6.9)

 

aRegression model adjusted for age, sex, annual household income, highest education attainment, 30-day readmission, 30-day emergency department visit, same-day length of stay, BMI, procedure (knee vs hip), osteoarthritis, comorbidities (solid tumor without metastasis, obesity, drug abuse, depression, hypertension).

difference between respondent and nonrespondent groups, it is not expected to meaningfully change the findings or conclusions of this study. In addition, although issues related to representativeness of sampling and generalizability of findings were minimized due to the survey being administered as a census, it was administered during the summer months. However, we do not anticipate the timing of survey administration to bias on our findings or make them less generalizable to patients who received total joint arthroplasty in other months. We did not separately assess outcomes for patients undergoing THA and TKA, and factors affecting care and outcome ratings may differ across populations. Patient satisfaction with care and with surgical outcomes is a complex phenomenon, and our survey instrument was not designed to exhaustively capture all potential predictors.

Several Kaiser Permanente regions have begun to use the findings about factors associated with higher care and satisfaction ratings in the preoperative phase of care. Patient education classes and materials have been improved to further increase the likelihood that patients’ expectations are congruent with their experiences. Similarly, strategies such as scripting to enhance surgeons’ communication about appropriate expectations and postoperative pain management have been identified and implemented.

Of the factors we identified, knowing what to expect before surgery pertains to preoperative care, and home health experience and knowing what to do about symptoms and pain during recovery pertain to post-discharge care. Coordination of information between providers and shared decision making are relevant to an entire episode of care. Our findings underscore the importance of assessing care and care experience throughout the entire episode of care for TKA and THA to identify actionable areas for improving patient satisfaction. The actionable factors reported in our study can be incorporated into total joint care to improve patient satisfaction.

Disclosure Statement

The authors have no conflicts of interest to disclose.

Acknowledgments

We thank the following individuals for input and insights that made this work possible and meaningful: David Glass, PhD, Heather Prentice, PhD, MPH, Tracy Cameron, MBA, MA, and Jenni Green, MS.

Author Affiliations

1Care Management Institute, Kaiser Permanente, Oakland, CA

2Now with Stanford Health Care, Stanford, CA

3Surgical Outcomes and Analysis Department, Southern California Permanente Medical Group, San Diego, CA

4The Southeast Permanente Medical Group, Atlanta, GA

5The Permanente Federation, Oakland, CA

6Southern California Permanente Medical Group, San Diego, CA

7The Permanente Medical Group, Oakland, CA

8Southern California Permanente Medical Group, Harbor City, CA

Corresponding Author

Margaret C. Wang, PhD, MPH (margaret.c.wang@kp.org)

Authors' Contributions

Margaret C Wang, PhD, MPH, participated in the study conception and design; acquisition, analysis, and interpretation of data; drafting, critical review, revising, and submission of the final manuscript. Elizabeth W Paxton, MA, PhD, and Jim Bellows, PhD, participated in the study conception and design; analysis, and interpretation of data; and critical review of the final manuscript. Priscilla H Chan, MS, participated in the study conception and design; data analysis; and drafting of the final manuscript. Kate Koplan, MD, MPH, Violeta Rabrenovich, MHA, Jeff Convissar, MD, Nithin C Reddy, MD, Christopher D Grimsrud, MD, PhD, and Ronald A Navarro, MD, participated in the study conception and design, acquisition and interpretation of data, and critical review of the final manuscript.

Funding Statement

No funding was received for this work.

Supplemental Material

Supplemental Material is available at: www.thepermanentejournal.org/files/2021/21.043supp.pdf

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Keywords: patient-reported outcome measures, patient satisfaction, quality improvement, replacement arthroplasty, total joint replacement

Abbreviations: BMI, body mass index; THA, total hip arthroplasty; TKA, total knee arthroplasty

 

Highly-satisfied patients (N = 2,781)

Non–highly-satisfied patients (N = 199)

Mean age, years

69.95

68.63

Sex,a n (%)

 

 

 

Female

1,641 (61.8)

127 (70.5)

 

Male

1,011 (38.2)

53 (29.5)

Education, n (%)

 

 

 

No high school

59 (2.2)

0 (0.0)

 

Some high school

78 (2.9)

7 (3.6)

 

High school graduate

457 (16.9)

36 (18.5)

 

Some college or Associate degree

951 (35.1)

66 (33.8)

 

Bachelor’s degree

429 (15.8)

32 (16.4)

 

Graduate or professional degree

737 (27.2)

54 (27.7)

Procedure type, n (%)

 

 

 

THA

1061 (38.2)

65 (32.7)

 

TKA

1720 (61.8)

134 (67.3)

Length of stay, days past midnight,a n (%)

 

 

 

0

1263 (45.4)

68 (34.2)

 

1

1226 (44.1)

99 (49.7)

 

2

204 (7.3)

19 (9.5)

 

3+

88 (3.2)

13 (6.5)

DxCG Concurrent Scorea

1.383

1.766

30-day utilization, n (%)

 

 

 

Readmissiona

35 (1.3)

9 (4.5)

 

Emergency department visita

219 (7.9)

26 (13.1)

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