Met expectations, symptom relief identified as factors for patient satisfaction

Nearly half of dissatisfied TKA patients reported stiffness, swelling at one-year postop.

Issue: June 2006

CHICAGO — The factors driving patient satisfaction have remained elusive. Now the results of a new patient questionnaire point to residual symptoms and expectations as indicators for satisfaction.

These conclusions arise from a survey of 253 unicompartmental total knee arthroplasty (TKA) patients, which found that 14% were dissatisfied with their new knee at one-year postop. Of those dissatisfied, 44% reported having residual symptoms. Investigators also discovered that more dissatisfied patients felt that they were not as active as they expected compared to the satisfied group (P<.0001), they wrote in their abstract.

“[In this study] patient satisfaction seems to be primarily determined by relief of symptoms and fulfillment of patients’ expectations of their knee function that they will get after knee arthroplasty,” Philip C. Noble, PhD, a professor and research director at Baylor College of Medicine in Houston, said during his presentation at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting.

“Surprisingly, the biggest indicator of patient satisfaction does not appear to be dependent so much on the biomechanical or kinematical performance of their knee rather than their expectations of what their knee will be like.” Noble and his colleagues won the American Association of Hip and Knee Surgeons’ John Insall Award for their research.

In the study, the research team asked patients to complete a Total Knee Functional Questionnaire at one-year postop. The questionnaire explored overall satisfaction with the surgery using a sliding scale and asked if the procedure met postoperative expectations. “[We asked] whether their knee keeps them from doing anything they want to do, whether it’s made them more or less active than they were before surgery and whether it provided the level of activity that they expected.” Noble said.

The questionnaire also polled patients on 43 high- and low-demanding activities. Patients noted the importance of each activity, how frequently they performed the task, and whether their knee hampered activity. “We also asked symptoms and what exactly was the frequency of postoperative stiffness, swelling or pain and whether their knee feels normal,” Noble said.

Nearly all of the respondents had a preoperative diagnosis of primary OA and 60% were women. The investigators used univariate and multiviate analysis to determine relationships between factors and patient satisfaction.

The researchers found that nearly half of dissatisfied patients still had symptoms. More dissatisfied patients reported swelling (P=.04) and stiffness (P<.0001) compared to satisfied patients, the researchers wrote. “It’s something like a 4.05 to 1 odds ratio for stiffness and a 2 to 1 odds ratio for swelling with dissatisfaction when the symptom is more frequent than once a week,” Noble said.

A univariate analysis also revealed the significance of patient expectations. “If we asked patients, ‘Are you as active as you expected?’ There is almost a two to one ratio [for satisfied vs. dissatisfied patients answering ‘yes’],” Noble said. Nearly half of dissatisfied patients noted that the surgery did not meet their pre-operative expectations for activity compared to 14% of satisfied respondents. “Dissatisfied patients also experienced significantly more difficulty in performing those functional activities of greatest personal importance (P=.008),” the researchers wrote.

Predicting satisfaction

After combining these factors for a multivariate analysis, the researchers could pinpoint satisfied patients. “The success of this strategy can be shown in the fact that we are able to display, with just three variables, 99% of the satisfied patients,” Noble said. “We can predict with the exception of only one or two patients [that are missed with this criteria] and that’s based solely on are they stiff after a year, are you as active as expected and can you do activities without symptoms that are important to you personally. These are the drivers for satisfaction.”

Yet, the researchers could not use criteria such as gender or activity level to easily filter out dissatisfied patients without symptoms from satisfied patients with residual symptoms. Noble concluded that expectations may hold the key to determining dissatisfied patients.

“In other words, they don’t have any symptoms doing all these activities,” he said. “They just expect more. What’s going on here?” Noble said that a new, prospective study will further explore the potential link between expectation and dissatisfied patients without symptoms.

The current research highlights the need for patient education. “Our findings, I think, reiterate the importance of the surgeon’s role in helping patients formulate reasonable expectations for the outcome of TKA,” Noble said.

For more information:
Noble PC, Conditt MA, Cook K, et al. Factors affecting patient satisfaction with total knee arthroplasty. Presented at the American Association of Hip and Knee Surgeons Specialty Day Meeting. March 25, 2006. Chicago.