Patient-centered care (PCC) is gaining considerable momentum among health care professionals and policy-making authorities. The need for PCC stems from the innumerable benefits of adopting such a system. The practice of PCC in orthopedic surgery in general, and in total joint replacement in particular, is still in its youth. However, present literature already establishes the need for applying PCC in total joint replacement. Extensive research and effort should be invested to better grasp and define the dimensions of PCC as they relate to total joint replacement.
Key points
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PCC is a fundamental principle that, although fully developed theoretically, is still in its youth in terms of clinical application.
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PCC in orthopedics and TJR in particular still needs to be expanded and studied more thoroughly, namely at the implementation level.
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The benefits of PCC necessitates that the practice start sooner rather than later, and that governmental agencies, institutions, and various stakeholders invest in setting up dedicated centers to that end.
Introduction
Over the last decade, the notion of patient-centered care (PCC) has been gaining considerable focus among the medical community. Although this concept dates back to the 1960s to 1970s and was discussed by scholars, such as Balint and Lipkin, the term itself was coined in 1988 by The Picker Institute. Since then, the implementation of care-delivery models in alignment with PCC concepts has been studied in various medical specialties including pediatrics, cardiology, and rheumatology. The impact of PCC on the health care system was significant, so much so that the Institute of Medicine (IOM) designated PCC as one of the six fundamental aims of the US health care system.
Total joint replacement (TJR) is considered the definite treatment of end-stage arthritis associated with certain indications to include pain, functional limitations, and stiffness. The procedure is considered one of the most efficient procedures in medicine because it leads to substantial improvement in quality of life. The estimated cost of primary TJR in 2015 exceeded $50 billion, and the rates are projected to increase in upcoming decades, especially with the increasing prevalence of the aging population. With the current rise in health care expenditures, optimizing the quality and the economics associated with health care delivery has become a necessity. As such, the PCC model is perceived as a valid and sustainable approach that might lead to the crucially needed improvement in health care quality, while simultaneously decreasing associated costs.
This article highlights the practice of PCC in TJR by focusing on the major attributes of PCC models and providing a brief comment on PCC-based clinical care pathways in joint surgery.
Introduction
Over the last decade, the notion of patient-centered care (PCC) has been gaining considerable focus among the medical community. Although this concept dates back to the 1960s to 1970s and was discussed by scholars, such as Balint and Lipkin, the term itself was coined in 1988 by The Picker Institute. Since then, the implementation of care-delivery models in alignment with PCC concepts has been studied in various medical specialties including pediatrics, cardiology, and rheumatology. The impact of PCC on the health care system was significant, so much so that the Institute of Medicine (IOM) designated PCC as one of the six fundamental aims of the US health care system.
Total joint replacement (TJR) is considered the definite treatment of end-stage arthritis associated with certain indications to include pain, functional limitations, and stiffness. The procedure is considered one of the most efficient procedures in medicine because it leads to substantial improvement in quality of life. The estimated cost of primary TJR in 2015 exceeded $50 billion, and the rates are projected to increase in upcoming decades, especially with the increasing prevalence of the aging population. With the current rise in health care expenditures, optimizing the quality and the economics associated with health care delivery has become a necessity. As such, the PCC model is perceived as a valid and sustainable approach that might lead to the crucially needed improvement in health care quality, while simultaneously decreasing associated costs.
This article highlights the practice of PCC in TJR by focusing on the major attributes of PCC models and providing a brief comment on PCC-based clinical care pathways in joint surgery.
Defining patient-centered care
A large number of institutions and experts have attempted to define and characterize PCC. The IOM defines PCC as “Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.”
Along the same lines, the American Academy of Orthopedic Surgeons defines PCC as “the provision of safe, effective, and timely medical care achieved through cooperation among the physician, an informed and respected patient (and family), and a coordinated healthcare team.”
The Picker Institute, one of the leaders in the patient-centeredness field, defines PCC based on eight fundamental dimensions: (1) respect for patient-centered values, (2) coordination and integration of care, (3) information and communication, (4) physical comfort, (5) emotional support, (6) involvement of family and friends, (7) transition and continuity of care, and (8) access to care.
Other definitions include that of the Planetree model health care, which “cultivate the healing of mind, body, and spirit; that are patient-centered, value-based, and holistic; and that integrate the best of Western scientific medicine with time-honored healing practices.” The Planetree model is based on nine integral attributes that significantly overlap with other institutions’ definitions. Other characterizations include those of the Ontario Medical Association, International Alliance of Patients’ Organizations, Institute for Family-Centered Care Model (family-centered care), and many others.
Even with this multitude of definitions and organizations associated with the conceptualization of PCC, the key attributes remain solid and constant throughout with substantial convergence. As such, it is evident that the insight on, definition of, and concept of PCC are widely established and available, whereas the challenge at hand remains to design the optimal delivery system.
The benefits of patient-centered care
Multiple studies have highlighted the positive impact of PCC on improving health care delivery models and patient outcomes. One of the main impacts of implementing PCC is the reduction of morbidity and mortality through targeting integral points in the treatment process, such as physician-patient relationship, communication, and active participation. Furthermore, there is better overall compliance with the course of therapy, a reduction in the impact of symptoms on the quality of life, and improvement of health care efficiency by limiting the underuse and overuse of available resources. Kim and colleagues, in an interview of more than 500 patients, reported that patient-perceived physician empathy improved patient satisfaction and compliance. In another study, PCC was shown to improve objective outcomes in which patients with type 2 diabetes achieved better control of glucose levels. Bertakis and Azari, in a randomized trial of more than 500 participants, noted a 51% decrease in expenses for patients that were treated with a more extensive PCC approach. As such, PCC has been proven to improve patients’ health status over a variety of value-metrics and variables, such as lessening discomfort along with better mental health, while simultaneously improving health care efficiency.
Patient-centered care in orthopedic surgery
Orthopedic surgeons are advocating for PCC as a successful care-delivery model that focuses on the patient’s needs, understanding, expectations, and preferences. The TJR literature still suffers from paucity in assessing and reporting patient satisfaction, choice of intervention, role of the patient in the decision-making process, and other integral parameters related to PCC. However, available research has shown that PCC positively impacts orthopedics and TJR patients, and additional efforts are currently underway to gain further knowledge. Even though various protocols and guidelines exist for standardizing certain aspects of care in TJR (ie, deep vein thrombosis perioperative prophylaxis), limited guidelines are available to provide physicians and institutions with appropriate means to establish and implement PCC in TJR.
Patient satisfaction
Patient satisfaction is one of PCC’s dimensions and is sometimes used as a proxy to assess the success of PCC implementation. Physicians who attain the highest rates of patient satisfaction are rewarded by their hospitals, and the government, through new reimbursement models. Although it is challenging to define, satisfaction is an integration of various experiences the patient handles in relation to preset expectations. Aside from expectations, other factors, sometimes unrelated to the disease process, also alter this parameter. A study by Bourne and colleagues has shown that living alone is one of the variables that correlate with patient dissatisfaction after TJR. Other factors that correlate with dissatisfaction following TJR, which ranges from 10% to 30%, are summarized in Table 1 , and include preoperative expectations and pain relief. There is substantial disparity in variables used to assess satisfaction as a TJR outcome.
| Patient-Specific | Patient-Physician | Surgeon-Specific |
|---|---|---|
| Preoperative condition (pain at rest, comorbidities, avascular necrosis) | Unmet expectations (the most consistent variable and one with highest impact) | Surgical approach (conflicting evidence) |
| Age at surgery (conflicting evidence) | Low functional outcome and residual symptoms | Complexity of the case (conflicting evidence) |
| Living alone, lack of social support | Postoperative complications | Hospital and surgeon volume (conflicting evidence) |
| Mental health status at baseline | Revision surgery | |
| Female gender (conflicting evidence) | ||
| Low income |
Among the available measurements, many are structured to focus on what surgeons deem important in affecting postoperative satisfaction, rather than centering on the patient’s values and perspective. Studies have established that patient satisfaction is a critical instrument in improving patient care and outcomes and positively impacting physicians’ job satisfaction, and reducing stress and burnout. Yet, measuring patient satisfaction in TJR, orthopedics, or medicine as a whole has always been a challenge. The American Academy of Orthopedic Surgeons was among the first within the surgical field to exhibit interest in measuring satisfaction using the Musculoskeletal Outcomes Data Evaluation and Management System questionnaire. Unfortunately, the project was later discontinued, in part because of lack of interest among orthopedic surgeons. However, analysis of this experience did provide valuable lessons for future large-scale data collection. Methods to minimize respondents’ burden, approaches to motivate physicians, and recommendations to expand the scope of involvement to include the community and government arose from this exercise. Other measurements currently in use include the Picker patient satisfaction tool, the Pay-for-Performance initiative tools, the Press Ganey Survey, and the Consumer Assessment of Healthcare Providers and Systems. Patient-reported measurement instruments routinely incorporated in perioperative outcomes assessment in orthopedics include the Oxford Hip and Knee Scores, Western Ontario and McMaster Universities Arthritis Index, Knee injury and Osteoarthritis Outcome Score, and Hip Disability and Osteoarthritis Outcome Score. Clinician-completed scores, such as the Knee Society Score, MAYO Wrist Score, and Harris Hip Score, are also available. Although these measures have been validated and are being used in research, they are widely heterogeneous in terms of collected variables. In addition, many of the validated measurements, such as the Oxford Hip Scores, are not designed to assess patient satisfaction primarily.
The implementation of patient-reported outcome measures in nationwide registries is an integral component of assessing the quality of TJR, and will form the major cornerstone in achieving an accurate assessment of patient satisfaction. However, the current variability and discrepancies in available instruments remains challenging, and research should continue, as described later, to develop the optimal tool for the specific measure in question.
Graham and coworkers highlight an integral issue concerning patient satisfaction measurement, emphasizing the need for a “right measure of outcome” tailored to the question to be answered. Adding to the current ongoing lack of a standardized instrument that assesses patients-perceived satisfaction, a clear distinction should be made between “satisfaction with the process of care and satisfaction with the outcome of care.” The outcome of care consists of factors that are influenced by the surgeon, such as patient expectations and physician-patient communication. However, the process of care is a more global and multidisciplinary series of events that span different departments and involve variables that are beyond the physician’s influence. Graham and coworkers indicate that orthopedic surgeons should focus on the measurement of factors on which they can have an impact. Although this is true, we advocate that the physician plays a much larger role and contribution to patient satisfaction with the entire process of care. Because this task might be daunting, future goals of the health care system should include designating specialized units with well-structured care pathways to achieve satisfaction with the entire spectrum of care delivery, including outcome and process of care. In relation to TJR, more extensive research is needed, and specific tools should be developed to take into account variables perceived as significant by patients. As Graham and coworkers eluded, these tools should distinguish between outcome and process of care satisfaction. Within the PCC context, future research should also focus on the factors that the patient recognizes as integral to satisfaction (eg, psychosocial, cognitive). Efforts should be invested in constructing centers capable of achieving patient satisfaction. Optimal care should be based on parameters, such as patient expectations, communication, follow-up care, and others that research might reveal to be of significance (eg, patient-surgeon interaction; staff hospitality and attitude; logistics of the center, such as parking spaces; presence of support group).
Communication
Communication is one of the dimensions of PCC set forth by the IOM. Successful communication is attained when a physician and a patient achieve a partnership in care, decision-making, and understanding of the disease, treatment options, and other aspects of the care process. Communication with patients should be based on sound, well-articulated skills that account for values, such as empathy, compassion, and humanism. Based on these values, the content of the communication should include the diagnosis, prognosis, and available disease-management options. Regardless of the method of communication, any interaction should be “attentive, responsive and tailored to an individual’s needs.” Available evidence highlights the benefits of optimizing communication and correlates it with an improved understanding of medical information, increased compliance with treatment, and increased likelihood of having more realistic expectations. More importantly, good communication culminates in increased patient satisfaction with the process of care. Ha summarizes many other beneficial outcomes of good physician-patient communication, such as improved recovery and psychological adjustments of the patients.
Similarly, studies have shown that communicating with patients and educating them about TJR leaves a positive impact before and after the surgical procedure. One study has shown that TJR candidates enrolled in a presurgical class focusing on patient needs, education, and potential benefit have an improved health quality. Communicating with family members and other patients with similar experiences also proved to improve health-quality. However, the level of communication in orthopedic surgery remains surprisingly suboptimal. In a study that assessed the implementation of informed decision by orthopedic surgeons, only 9% met the criteria of informed decision. In another study by Tongue and colleagues, patients reported that only around 30% of surgeons took enough time to communicate with them. Interestingly, 75% of orthopedic surgeons believed they were taking the time needed to communicate properly with patients, whereas only 20% of surgeons believed that their peers spent enough time and practice proper communication techniques with patients. These alarming results emphasize the lack of proper communication between orthopedic surgeons and their patients.
A study assessing factors affecting a patient’s decision to undergo a TJR showed that one of the main reasons to avoid surgery is the false perception of the low impact of the procedure on current health status. Other factors correlating with unwillingness to undergo TJR include low expectations in relation to postoperative pain relief and improved functionality. Because current evidence supports the substantial improvement in quality of life following TJR, the results of the aforementioned studies indicate a huge gap in communication between patients and their care providers, whether surgeons or primary care physicians (PCP). Communication between patients and orthopedic surgeons is also needed to guarantee a solid understanding and more realistic expectations by the patient of what the intervention may and may not provide. In a study assessing patient satisfaction following TJR, a major reason for dissatisfaction was the failure to meet preoperative expectations, which may be easily avoided using proper preoperative communication.
Communication is a multifaceted process and also involves the PCP-patient interaction as previously suggested. Schonberg and colleagues reported that the surgical option as a treatment modality for patients with severe osteoarthritis was neglected and never discussed by the PCP in many cases. The authors also noted that patients were more likely to undergo the procedure when the PCP presented surgical intervention as a viable option. Some studies attribute the PCP’s omission of TJR as a treatment modality for severe osteoarthritis to the underestimation of the procedure’s effectiveness and respective impact. There is a crucial need for establishing a better communication between the PCP and the patient, and also between various providers and stakeholders in the health care delivery loop. The patient must remain centralized in these interactions.
Communication requires the combined efforts and active participation of the patient, PCP, surgeon, family, administrators, and anyone involved in the health care system ( Fig. 1 ). Even though communication should always cover the essentials of informed consent (diagnosis, prognosis, alternatives), it should also include the patient’s expectations, needs, perspectives, social values, and other aspects of care. Communication involves educating the patient and also serves as an educational process to the surgeon and the PCP to treat the patient rather than the disease. Finally, the gap in communication between PCP and orthopedic surgeons should also be filled to avoid delay in patient care. To that end, the health care system should invest in centers dedicated to PCC. These centers should tie together the different variables in this complex equation. It should also oversee and guide the communication needed, by the different technologies at hand, in a coherent integrated flow that is evidence-based and patient-centered.
Related posts:
Approach to Decrease Infection Following Total Joint Arthroplasty
Patient Centeredness in Total Joint Replacement
Anterior Cruciate Ligament Injuries in Children and Adolescents
Reducing 30-day Readmission After Joint Replacement
Tibial Stress Fractures in Athletes
Thumb Ligament Injuries in the Athlete
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