To What Degree Do Patients' and Clinicians' Ratings of Appropriateness of TKA Align, and Were Expected Outcomes Associated With Those Ratings?

Background: TKA is performed only after the patient and the surgeon agree that the potential benefits of surgery outweigh potential risks. However, as many as 20% of patients are dissatisfied after TKA, suggesting that the shared decision-making process does not consistently serve our patients well. Expected outcomes are increasingly used in clinical practice, as an addendum to preoperative clinical and demographic factors, to inform this decision; however, the added value of this information in aligning patients and surgeons regarding the benefit and risk of TKA remains poorly understood.

Questions/purposes: (1) How do patients' ratings of appropriateness of TKA (based on benefits and risks as appropriate, inappropriate, or inconclusive) compare with clinicians' ratings of appropriateness for 279 hypothetical patient scenarios that include both preoperative factors and expected outcomes? (2) Did expected outcomes drive the patients' ratings? (3) What additional factors, not accounted for in the hypothetical patient scenarios, also affected the patients' ratings of appropriateness of TKA for these scenarios?

Methods: TKA appropriateness ratings for 279 hypothetical patient scenarios were previously developed using the RAND/UCLA Delphi method and rated by a panel of clinicians as either inappropriate, inconclusive, or appropriate. These scenarios are composed of clinically plausible permutations of five preoperative factors and three expected postoperative outcome factors. Expected outcomes were shown to be the most important drivers of physicians' classification. In this study, a panel of eight patients (four with end-stage osteoarthritis [OA] without TKA and four who recently underwent TKA) independently rated the appropriateness of TKA for the same 279 scenarios on a scale from 1 to 9 (1 to 3 were considered inappropriate, 4 to 6 inconclusive, and 7 to 9 appropriate). These patients were identified by the Arthritis Foundation with equal representation of men and women who had TKA and those who did not and were educated on the clinical meaning and relevance of each factor. The median score rating was then classified into either "inappropriate," "inconclusive," or "appropriate," and categories were compared with those of the clinicians for the same scenarios. Classification tree (CART) analysis was applied to the patient-assessed TKA appropriateness categories to identify the most influential of the eight factors. After completing the appropriateness ratings, the same eight patients were convened in two focus groups to elucidate qualitatively any additional factors that influenced their ratings. Semistructured interviews were conducted, and qualitative methods were applied to the narrative to determine these additional factors.

Results: Based on patients' median score for the 279 scenarios, 15% (43) of scenarios were classified as inappropriate, 53% (148) of scenarios as inconclusive, and 32% (88) of scenarios as appropriate. Overall, concordance between the patient and the surgeon classifications was 68% (weighted κ = 0.58 [95% confidence interval 0.51 to 0.66]; p < 0.001). None of the scenarios that the clinicians classified as appropriate were classified as inappropriate by the patients and vice versa. Preoperative symptom severity, OA radiographic severity, expected rate of serious complications, and expected improvement at 2 years were crucial factors that discriminated among the patient-assessed TKA appropriateness classification categories. The semistructured qualitative interviews with the same eight patients from focus groups identified risks of opioid addiction and fear of functional deterioration as additional important factors for patients to consider TKA earlier.

Conclusion: When expected outcomes were included as part of a clinical scenario, patients generally agreed with the clinicians when a TKA was appropriate, suggesting that expected outcomes may further increase concordance between patients and surgeons.

Clinical relevance: Incorporating expected outcomes into clinical practice and engaging patients to understand all the factors affecting their decisions may aid surgeons in guiding the shared decision-making process and ultimately reduce dissatisfaction with the outcome of surgery.