Delivering “The Patient Experience” With the Direct Anterior Approach

Maiken Jacobs

Matthew M. Levitsky

Jeffrey A. Geller

Roshan P. Shah

Introduction

Setting appropriate expectations with the direct anterior approach (DAA) for total hip arthroplasty (THA) helps to form the foundation for successful surgical recovery. The DAA may be more unique in the vector of expectation adjustment in that some patients have baseline expectations for surgery that are much lower than what DAA offers (eg, they heard about the “old” experience of their grandparent from 20 years ago) and others have far too high expectations (eg, from reading marketing anecdotes or selected testimonials from highly successful patients). Therefore, much of the delivery of “the patient experience” is focused on education, preparation, and information. In this chapter, we describe our process for setting expectations and education of patients and families in order to drive the patient experience toward satisfaction and success.

Preoperative Patient Education

Preoperative patient education is an educational intervention delivered before a surgical procedure that is designed to improve a patient’s health behaviors, health knowledge, and health outcomes.¹ Although many patient education programs consist of self-administered written and audiovisual materials, most experts agree that a key component of a successful patient education program is an interactive live class delivered in person via a face-to-face encounter (including telehealth) or a telephone session with clinical patient educators. These live classes, which allow the opportunity for patients and caregivers to ask clarifying questions; assist with physical, emotional, and logistical preparation; and facilitate care coordination across the continuum of the surgical process, are considered to be the most effective ways to deliver the educational material (Table 51.1). Indeed, studies suggest that a patient’s inclination to proceed with surgery is influenced by how well their questions are answered during the preoperative education experience.

TABLE 51.1 Sample of Preoperative Education Class Content for Total Hip Replacement (THR)

Office visit preparation	Preoperative preparation	In-patient hospital stay preparation	Discharge planning
Explanation of the nature of pathology and need for THR	Preadmission testing, medical and anesthesia clearance	Nursing care	Adaptive equipment and adaptive device training overview
Type of THR approach and surgical technique	Nutritional counseling and initiation of supplements	Rehabilitation therapy (physical therapy/occupational therapy, early mobilization on day of surgery)	Infection prevention/antibiotic prophylaxis
Risks of THR	Prerehabilitation exercises	Pain medications	Discharge planning (hospital discharge time, pickup person, postoperative therapy arrangements)
Encourage/mandate participation in preoperative education class	Medication adjustment	Preventing postoperative complications	Recovery at home (realistic expectation setting of postoperative pain management, nutrition, exercises, bruising and edema management, wound/dressing management, home exercise)
Anesthesia options (with explanation on the benefits of certain types for rapid recovery)	Decrease use of narcotics	Gastrointestinal management	Follow-up appointments
Medications (pre- and postoperative management; focus on pain management)	Smoking cessation	Deep vein thrombosis prophylaxis	Understanding the care team/contacts and numbers
Expectations regarding hospital length of stay (ambulatory surgery vs short inpatient stay with discharge on postoperative day 1 or 2)	Weight loss management/referral to bariatrics for comanagement if needed	Incentive spirometry
Discharge/recovery expectations (most patients are discharged directly home with home care physical therapy, telehealth visit physical therapy, or outpatient physical therapy; very few patients need inpatient rehabilitation at a facility)	Bowel preparation preoperatively to address potential constipation	Case management and social worker consultation for posthospital needs
	Use of CHG cleanser
	What to bring to the hospital
	Home preparation: selecting a “coach”
CHG, chlorhexidine.

In-person face-to-face encounters with the patient and family also deepen the engagement of patients and commitment to their recovery.² This engagement can redirect the recovery process to focus on postsurgical issues rather than assuming an uneventful experience. This is important at a time when DAA hip replacement has increasingly become an outpatient procedure with short recovery times.

As the environment around DAA hip replacement continues to evolve, the information available to the public also has evolved and matured. Earlier periods skewed toward more discussion of the benefits and incomplete consideration of complications.³ Modern discussions should be balanced, and benefits are now well supported by the literature and experience. Nonetheless, it is valuable to maintain accurate personal outcomes data to inform a discussion of risks of fracture, dislocation, and infection and weigh them against the well-marketed benefits of anterior hip replacement.

Goals and Objectives of Preoperative Education

Preoperative education is the most effective method for managing patient and family expectations regarding total hip replacement (THR). The goals and objectives of preoperative education encompass three broad domains: (1) the patient (and caregiver) domain, (2) the physician domain, and (3) the hospital domain. The patient-level domain includes improving health literacy regarding joint replacement, reducing patient and caregiver anxiety, improving the patient’s overall experience, and accelerating the patient’s recovery. The physician-level domain includes aligning patient expectations with the physician’s expectations based on surgical technique and comorbid conditions and increasing the likelihood that patients will agree to have the surgery. The hospital level is centered on improving patient satisfaction and lowering hospital length of stay.

The Patient (and Caregiver) Domain

Preoperative patient education begins in the office with the surgeon and continues through the patient’s postoperative recovery period. Consistent, clear, and effective communication among the patient’s interdisciplinary care team members is critical for meeting the goals and objectives of preoperative education. First impressions from the surgical consultation are important and can set the tone for driving the patient experience. In our practice, we emphasize the most important optimization interventions for individuals. For example, diabetics learn about the importance of tighter glucose control, the obese learn about newer carbohydrate-controlled diets, and sarcopenic patients are taught strengthening exercises.

These themes for preparation and optimization are repeated and reinforced in a patient-centered preoperative education class. During the class, it is useful to learn what the patient already knows and supplement this baseline knowledge with personalized information regarding the DAA surgical technique and the expected recovery process and anticipate postoperative needs. The preoperative education class is best delivered by members of the orthopaedic clinical staff with experience and/or training as educators. Ideally, classes should be mandatory before elective THA, and surgeons should be notified of any
patient failing to participate. As previously discussed, this lack of engagement alerts an enlightened surgeon to reassess patient expectations and commitment and to consider potential compliance issues after surgery. In specific high-risk cases, the authors will postpone surgery when additional preoperative education and preparation are needed.

Preoperative educational content varies from institution to institution, but typical educational materials include preparation for hospital experience, description of the surgical procedure, postoperative recovery and care, discharge processes and disposition, potential complications, postoperative medication management, and important contacts and follow-up appointments. Physical in-person classes may offer an advantage over virtual classes by conducting them near the orthopaedic floor in a vicinity that allows patients and caregivers to familiarize themselves with relevant hospital areas and staff, which has been shown to decrease preoperative anxiety.¹ It will be important to continue to evaluate the efficacy of online training, especially in the setting of a pandemic when patients might prefer to do more learning in the comfort of their own homes. Recorded classes will often include a tour of the facilities and can be thorough in the educational preparation, with the additional benefit of allowing repeated views and sharing with caretakers and family members who may not have joined a physical class.

When conducting a preoperative class, it is important to use layman’s terms and avoid medical jargon. Educational content should be delivered at a sixth-grade comprehension level and introduced chronologically. They should contain verbal descriptions and hands-on demonstrations by the educator using props such as hip models (or their virtual equivalent) and visual images. Providing educational materials at an appropriate literacy level for the patient is a key component of achieving successful recovery outcomes. With regard to joint arthroplasty, studies suggest that patients with low health literacy had lower expectations for mobility after surgery, which may contribute to unwillingness to want THR.⁴ Patient education materials should also be accessible to patient families and caregivers as studies reveal a strong correlation between a patient’s support system and patient outcomes. Leveraging these social support structures to identify a “recovery coach” (a designated member of the support team such as a spouse, child, or close friend) to participate in classes and assist in the patient’s recuperation has also been shown to improve patient outcomes. Studies evaluating the effectiveness of preoperative patient education suggest that this activity can reduce anxiety; improve a feeling of social connection; enhance a patient’s sense of independence and confidence for recovery; and improve compliance with therapy and pain medications, coping skills, and a patient’s overall sense of control.¹

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