Relationship between Realistic Preoperative Expectations ... … · 1 ABSTRACT 2 Introduction: To...

Relationship between Realistic Preoperative Expectations and Good Long-term Outcomes for

Persons with Planned Lower Limb Amputation

Allison Cerutti, MPO Candidate, BSBE

Faculty Mentor: Stefania Fatone, PhD, BPO(Hons)

Northwestern University Prosthetics-Orthotics Center

Chicago, IL 60611

ABSTRACT 1

Introduction: To examine the relationship between preoperative expectations and long-term 2

postoperative outcomes in persons with planned lower limb amputation (PLLA), this project 3

aimed to: (1) define “patient expectations” and (2) analyze expectation measurement within a 4

model population where there is research available, lower limb total joint arthroplasty (TJA), in 5

order to make recommendations for measuring expectations of persons with PLLA where there 6

is no research yet. Materials and Methods: A Delphi survey was used to define “patient 7

expectations.” To contextualize the Delphi results and make recommendations for future study, 8

we reviewed literature on expectation measurement for TJA. First, we indexed items within 9

existing expectation measures according to “expectation themes” and “expectation measurement 10

methods.” Second, we analyzed existing methodologies investigating the relationship between 11

preoperative expectations and postoperative outcomes. Results: Though the Delphi survey did 12

not result in a complete definition, two components derived from it are suggested for inclusion in 13

a new definition: “expectation themes” and “expectation measurement methods.” Trends in 14

existing expectation measures suggested that a future measure for PLLA should represent the 15 15

expectation themes found relevant by the Delphi survey and measure using “order of 16

magnitude.” Lastly, we selected an existing methodology from the review and adapted it for 17

future study of the relationship between expectations and outcomes in persons with PLLA. 18

Conclusions: To complement existing expectation measures, a future definition of patient 19

expectations should contain expectation themes and measurement methods. Overlap in 20

expectation themes between persons with TJA and PLLA supports our rationale to model future 21

expectation measurement for persons with PLLA after existing TJA measurement. 22

Keywords: lower limb amputation, total joint arthroplasty, preoperative expectations, expectation 23

measurement 24

25

Abbreviations: 26

Expectation Themes PF = physical functioning MF = mental functioning CF = cognitive functioning FI = functional independence P = pain SL = sleep HI = health improvement N = return to normal activities C = coping D = disability TE = treatment effectiveness TC = complications of treatment TO = treatment outcome R/S = risk/safety F = fears S/C = social/cultural role S = overall satisfaction with care QOL = health-related quality of life PC = personal challenges associated with rehabilitation C/A = cosmesis/appearance

SX = sexual activity S/R = sports and recreation/leisure activity R = recovery time E = employment/vocational activity

Expectation Measurement Methods OM = order of magnitude DI = degree of importance P = probability OE = open-ended

27

INTRODUCTION 28

Healthcare institutions in the U.S. have employed “patient-centered care” as a means to 29

improve quality of care.1-3 Patient-centered care incorporates two key constructs for clinicians to 30

measure: patient-reported outcomes (PROs) and patient expectations.1-4 To measure PROs, 31

healthcare institutions have adopted self-report instruments,5 e.g. questionnaires.4, 6, 7 Unlike the 32

established measurement of PROs, a recent review8 highlighted the difficulties of measuring 33

patient expectations given lack of a theoretical foundation for conceptualizing this construct. The 34

contradictory terminology8-10 and classification systems8-12 presently defining patient 35

expectations have impeded development of measurement guidelines.6, 8 Despite these 36

shortcomings,8 a growing body of literature4, 6, 8, 11, 12 has attempted to measure expectations of 37

patients awaiting surgery to investigate the relationship between preoperative expectations and 38

postoperative outcomes. Results have been ambiguous thus far.6 The importance of exploring 39

this relationship remains. 40

The long-term goal of this work is to examine the relationship between preoperative 41

expectations and long-term postoperative outcomes, specifically from the perspective of patients 42

undergoing planned LLA (PLLA). We have defined PLLA as a planned (or elective) amputation 43

procedure secondary to severe vascular dysfunction. We hypothesize that clinicians’ expertise 44

together with patients’ values can shape patients’ expectations. Additionally, shaping 45

expectations realistically will increase the likelihood for positive long-term outcomes for persons 46

with PLLA. 47

One impediment to exploring our hypotheses is the dearth of literature needed to guide 48

methodology. Only two studies have attempted to measure expectations of persons with PLLA. 49

The first study13 compared preoperative expectations of pain to actual postoperative pain. The 50

second study14 identified expectation themes through patient interviews, none of which related to 51

pain. This is despite the fact that the first study13 indicated the importance of pain expectations, 52

suggesting the themes identified within the second study14 are incomplete. From this limited 53

literature, two needs arise: (1) a clear definition of expectations of persons with PLLA, including 54

a comprehensive list of themes, and (2) better understanding of how to measure preoperative 55

expectations. 56

Due to the dearth of PLLA literature, this project proposed learning from a model 57

population for which there is abundant expectations literature11, 12, 15-17—lower limb total joint 58

arthroplasty (TJA). Both TJA and PLLA are surgical solutions to end-stage chronic disease, 59

osteoarthritis and vascular dysfunction, respectively. With similar rationales for electing surgery, 60

patients may share expectations. Some studies12, 16, 17 suggest decreased pain is the most 61

important expectation of persons with TJA. The theme of “pain” in the first study13 to measure 62

expectations of persons with PLLA provides rationale that these populations have overlapping 63

expectations. 64

The purpose of this project is to address the above needs through two aims: (1) to define 65

the construct of patient expectations as it applies to the general population and persons with 66

PLLA and (2) to analyze how expectations have been measured in the model population (persons 67

with TJA) in order to make recommendations for measuring expectations of persons with PLLA. 68

METHODS 69

Aim 1—Delphi Survey 70

Survey Design 71

To address the first aim, a Delphi survey was conducted to collect opinions on current 72

definitions and terminology describing patient expectations and to generate consensus 73

statements. Consensus statements were intended to (1) guide future development of a definition 74

of patient expectations specific to persons with PLLA, and (2) inform the Aim 2 literature 75

review. The Delphi Technique uses iterative survey rounds to derive consensus from among 76

“expert” opinions.18 Delphi surveys are often used to explore research areas, such as this one, 77

that are ambiguous and lack consensus.18 78

Prior to panel selection, a preliminary review of general expectations literature was 79

conducted6, 8, 11, 12, 14 to create questions for Round 1. Round 1 comprised two parts: (1) defining 80

patient expectations in the context of general surgical populations, and (2) identifying 81

expectation themes to describe expectations of persons with PLLA. The first part contained five 82

questions and asked participants to evaluate existing definitions of patient expectations and to 83

identify terminology—called “features”—that should be included in a new definition. With the 84

intention to guide future expectation measurement, participants were also asked to evaluate 85

existing measurement methods. Finally, participants were asked which features clinicians could 86

shape. The second part asked participants to rate the relevance of 20 themes8, 14 to expectations 87

of persons with PLLA. Free text response options were available to record additional participant 88

insights. Round 2 consisted of statements generated based on responses from Round 1. 89

Selection of Expert Panel 90

Members of the “expert” panel were identified by convenience sampling of professionals 91

known to the investigator (author AC). Three criteria were used to identify potential panelists: 92

1. Potential interest in defining “patient expectations” of persons with PLLA; 93

2. Email address available; 94

3. Access to internet (for completing and submitting online surveys). 95

Individuals were considered potentially interested in “patient expectations” if they had 96

experience in any of these areas: prosthetics, physical therapy training persons with LLA, 97

amputation surgery, general medicine treating persons with LLA, and/or undergoing LLA. 98

Hence, “experts” were selected from among certified prosthetists, physical therapists, surgeons, 99

physicians, and persons with LLA. This pilot project aimed to include at least six “expert” 100

panelists in the following proportion: one certified prosthetist, one physical therapist, two 101

surgeons or physicians, and two persons with LLA. 102

Administration of Survey 103

The survey was created and distributed online via SurveyMonkey (SurveyMonkey Inc, 104

SurveyMonkey.com, California, USA) and comprised two rounds. Though no evidence suggests 105

an ideal number of rounds, studies have commonly reported two or three rounds.18, 19 106

Institutional Review Board (IRB) approval was not needed because the survey did not constitute 107

human subjects research.19 Appendix A contains screenshots of the survey. 108

Individuals who met inclusion criteria were invited to participate in the survey via email. 109

The invitation introduced the project and its aims, described the Delphi survey process, and 110

detailed participant expectations, including estimated time to complete Round 1, deadline for 111

survey submission, and estimated timeframe for the entire survey process. A second email 112

containing the survey link was sent to those who consented participation. Because 113

SurveyMonkey maintains anonymity of responders, participants were asked to confirm survey 114

submission via email to the investigator. In this way, only participants who completed Round 1 115

were asked to participate in Round 2. Confirmation of submission did not link responses to 116

individuals, thereby maintaining anonymity of responders. 117

In Round 1, consensus was defined as greater than or equal to 70% agreement.18, 19 118

Percentage agreement was calculated for each response within each question. For each question, 119

responses with consensus were collated into a statement(s). Each statement was presented in 120

Round 2 and participants were asked to agree or disagree. For any disagreement, explanation was 121

requested using free text response format. In Round 2, percentage consensus was again 122

calculated for each proposed statement. 123

Aim 2—Literature Review 124

Study Design 125

To address the second aim, a two-part, “semi-structured” literature review was 126

conducted. The semi-structured literature review employed a formal search strategy but did not 127

adhere to evidence-based guidelines for reporting of systematic reviews.20 For example, this 128

review did not assess risk of bias within individual studies nor across studies.20 Part 1 identified 129

existing expectation measures and aimed to index individual items within each measure 130

according to three categories that paralleled the Delphi consensus statements. Part 2 identified a 131

subset of studies within Part 1, which investigated the relationship between preoperative 132

expectations and postoperative outcomes. This subset was analyzed for expectation and outcome 133

variables and methods used to compare expectations to outcomes. Ultimately, results of the 134

review were intended to (1) guide future development of an expectation measure for persons 135

with PLLA, and (2) recommend a methodology(ies) by which to study the relationship between 136

expectations and outcomes. 137

Search Strategy 138

The investigator conducted a search in PubMed from inception through December 2014. 139

The search strategy used free text and MeSH terms (whenever possible). Varied search terms 140

describing total hip arthroplasty, total knee arthroplasty, and lower limb amputation (e.g. “total 141

hip arthroplasty” or “total hip replacement”) were used. The Boolean “AND” operator combined 142

population terms with terms describing “patient-reported,” “patient,” and “preoperative” 143

expectations, which were in turn combined with “measure,” “questionnaire,” or “measurement.” 144

Filters such as “free text,” “English,” and “humans” were applied. Titles and abstracts of the 145

initial search results were reviewed for preliminary “relevancy” criteria: (a) total hip or knee 146

arthroplasty or LLA study population, and (b) mention of expectation measurement. 147

Study Selection 148

Full text versions of all studies that met relevancy criteria were reviewed for final 149

inclusion. Additionally, the references of these relevant articles were searched and relevant 150

references were also reviewed for final inclusion. Table 1 lists the inclusion and exclusion 151

criteria for Parts 1 and 2 of the literature review. 152

Data Extraction & Analysis 153

The investigator extracted all data. In Part 1, individual items comprising expectation 154

measures were indexed within these categories: expectation theme, expectation feature, and 155

expectation measurement method. Frequency data within each category were used to identify 156

trends in how expectations are currently being measured. These trends were compared to results 157

of the Delphi survey pertaining to expectation themes, features, and measurement methods. In 158

Part 2, the following information was extracted from each included study: expectation 159

variable(s), outcome variable(s), and discrete comparison(s). A discrete comparison was defined 160

as a comparison between an expectation variable and outcome variable, as defined in Table 1. 161

Additionally, it was noted when a comparison(s) between preoperative expectations and 162

postoperative outcomes was the primary study objective. 163

Each discrete comparison was labeled in two ways: (1) by type, according to types of 164

expectation and outcome variable, and as (2) “complementary” or “non-complementary.” 165

Complementary comparisons used expectation and outcome items that complemented one 166

another regarding themes and measurement methods. For example, a study13 measured pain 167

expectations according to order of magnitude and compared pain expectations to pain outcomes, 168

measured according to the same scale. Conversely, non-complementary comparisons used items 169

with discordant themes and/or measurement methods. For example, another study9 measured 170

expected order of magnitude of pain and activity limitation and expected probability of success 171

and complications; these expectations were compared to the order of magnitude of satisfaction 172

outcome. Neither themes nor measurement methods were complementary in this example. 173

Within each study, characteristics of its methodology were analyzed: comparison type(s), 174

complementary vs. non-complementary comparison(s), and primary objective of the study. The 175

goal of this analysis was to identify a study or studies’ methodology(ies) for future use (or 176

modified use) in a study to compare expectations and outcomes in persons with PLLA. To do so, 177

the investigator determined which comparison type was best suited and whether its measures 178

should be complementary or non-complementary. Comparisons within studies whose primary 179

objective was not to compare preoperative expectations to postoperative outcomes were 180

excluded. Ultimately, the investigator aimed to make a recommendation for future research 181

based on the selected methodology(ies), including any necessary modifications. 182

RESULTS 183

Aim 1—Delphi Survey 184

Participation throughout the Delphi survey is illustrated by Figure 1. Twelve individuals 185

were invited to participate and ultimately six participated in Round 1 and four in Round 2. Figure 186

2 shows the demographics of those panelists who confirmed participation in each Delphi round. 187

Figure 2 compares target demographic distribution to actual distribution achieved in Rounds 1 188

and 2. 189

Round 1 190

For Round 1, percentage response agreement for each question is shown in Tables 2a-2d. 191

Because no responses were received for Question 4, which was optional, it is not shown. Based 192

on free text responses to Question 1, there was apparent confusion interpreting the question and 193

understanding its content. Subsequently Questions 1 and 4 were eliminated from Round 2. Using 194

responses to the remaining questions from Round 1—2, 3, 5 and 6—six statements were 195

generated and presented to the panel in Round 2. 196

Round 2 197

In Round 2, unanimous agreement was reached on all six statements. These statements 198

are also shown in Tables 2a-2d. 199

Aim 2—Literature Review 200

Results of the literature review are illustrated by Figure 3. Initial search results yielded 201

378 studies. After removing duplicates, 34 articles met preliminary “relevancy” criteria and an 202

additional 27 articles were identified through their references. Of these 61 articles, 50 were 203

included in Part 1 of the Aim 2 literature review.6, 9, 11-13, 15-17, 21-62 Of those 50 included in Part 1, 204

16 were included in Part 2.9, 13, 16, 17, 24, 26, 27, 29, 31, 33, 38, 40, 48, 51, 53, 62 205

Part 1 206

Within the 50 included studies there were five review papers.6, 11, 12, 21, 22 Expectation 207

measures and items were extracted directly from the included studies of these five reviews. 208

Overall, expectation measures and items were extracted from 45 studies9, 13, 15-17, 23-62; one study13 209

pertained to lower limb amputation and the remaining pertained to total hip or knee arthroplasty. 210

This resulted in 483 expectation items total. The items were indexed according to two of the 211

intended categories: expectation theme and expectation measurement method. Items could not be 212

indexed according to expectation feature. 213

Expectation theme. The 483 items were indexed to 18 expectation themes. Fourteen 214

themes were from the original 20 included in the Delphi survey: physical functioning, mental 215

functioning, functional independence, pain, sleep, health improvement, return to normal 216

activities, disability, complications of treatment, treatment outcome, fears, social/cultural role, 217

overall satisfaction with care, and health-related quality of life. An additional four themes were 218

identified as a result of the Aim 2 review: sexual activity, sports & recreation/leisure activity, 219

recovery time, and employment/vocational activity. The frequency of each expectation theme is 220

shown separately for the 14 original (Figure 4) and 4 new themes (Figure 5). 221

Delphi panelists agreed that 15 of the 20 expectation themes were relevant to persons 222

with PLLA. Hereinafter these 15 themes are called “relevant themes.” Figure 6 shows that the 223

majority of items (75%) were indexed to relevant themes. However, no items were found for 224

four relevant themes: treatment effectiveness, risk/safety, personal challenges associated with 225

rehabilitation, and cosmesis/appearance. Figure 7 shows the distribution of the remaining 11 226

relevant themes. Three themes are favored: physical functioning, return to normal activities, and 227

pain (together accounting for 85%). 228

Expectation measurement method. Figure 8 illustrates the distribution of the four 229

expectation measurement methods across all items: order of magnitude, degree of importance, 230

probability, and open-ended. Five items could not be indexed to a measurement method because 231

of insufficient detail and so were labeled “not applicable”.53, 57 232

The Delphi process arrived at three consensus statements concerning measurement 233

methods, collectively stating that “anticipations,” “desires,” and “needs” should be measured 234

using all four methods. Because the items could not be indexed according to features (e.g. 235

anticipations, desires, and needs), these statements could not be compared to trends in existing 236

expectation measures. Instead, distribution of measurement methods within each theme was 237

assessed (Figure 9). 238

Part 2 239

Twenty-eight discrete comparisons were identified within the 16 included studies. Nine 240

studies included multiple comparisons.9, 16, 17, 24, 27, 31, 40, 48, 51 241

Comparison type. Expectation variable was described by four types: E1, E2, E3, and E4. 242

Outcome variable was described by four types: O1, O2, O3, and O4. Table 3 provides definitions 243

of each type. Using expectation and outcome variable descriptors, 11 comparison types were 244

identified among the 28 discrete comparisons. Table 3 shows the number of studies in which 245

each type appeared. 246

Complementary vs. non-complementary. Ten discrete comparisons were considered 247

complementary; eighteen were considered non-complementary. 248

Primary objective. Five studies’ purpose statements13, 26, 33, 38, 48 stated that their primary 249

objective was to compare preoperative expectations to postoperative outcomes. 250

Recommendation for future study methodology. Comparison type “E4/O4” (“level of 251

expectations” compared to “level of outcomes”) was selected as most appropriate for a future 252

study to compare expectations and outcomes in persons with PLLA. Additionally, 253

complementary themes and measurement methods should be used. Though five studies17, 24, 31, 48, 254

62 included comparison type “E4/O4,” only Nilsdotter, Toksvig-Larsen, and Roos48 stated that 255

their primary objective was to “analyze the relationship between preoperative expectations and 256

self-reported improvement of physical function and pain.”48, p55 Also, only this study48 used 257

complementary measures. Hence, this methodology48 was selected as the basis for 258

recommendation for future studies. 259

DISCUSSION 260

The purpose of this project was to resolve ambiguity surrounding “patient expectations” 261

in order to guide future study of the relationship between expectations and outcomes for persons 262

with PLLA. The project had two aims: (1) to define the construct of patient expectations as it 263

applies to both the general population and persons with PLLA and (2) to analyze how 264

expectations have been measured in the model population (persons with TJA) in order to make 265

recommendations for measuring expectations of persons with PLLA. 266

The Delphi survey did not completely achieve Aim 1 as it did not result in clear 267

definitions of patient expectations for the general population and persons with PLLA. Based on 268

the preliminary literature review, the Delphi survey explored three potential components of a 269

definition: expectation features, expectation measurement methods, and expectation themes. The 270

Aim 2 literature review revealed a disconnect between the terminology (e.g. expectation 271

features) used to describe patient expectations in the literature and the wording used in existing 272

expectation measures. Despite this disconnect, expectation themes and measurement methods 273

made sense in the context of the Aim 2 review and thus, may still be suitable components of a 274

definition of patient expectations. 275

The two-part, Aim 2 literature review successfully analyzed how expectations have been 276

measured in persons with TJA. This review contextualized terminology used in the Delphi 277

survey (e.g. expectation themes and expectation measurement methods) within existing 278

expectation measures. 279

Expectation Themes 280

Delphi panelists unanimously agreed upon 15 themes relevant to persons with PLLA. 281

Eleven of the relevant themes were represented by 75% of the existing expectation items; these 282

items are likely applicable to measuring expectations of persons with PLLA. That the majority of 283

themes were of those relevant to PLLA supports the rationale that expectation themes between 284

TJA and PLLA overlap to some extent. However, a limitation of this overlap is demonstrated by 285

the four relevant themes not found among the expectation items. New items would be needed to 286

reflect these other relevant themes: treatment effectiveness, risk/safety, personal challenges 287

associated with rehabilitation, and cosmesis/appearance. These themes may not have appeared 288

within existing expectation measures because they are irrelevant to persons with TJA. The 289

Delphi question on themes targeted persons with PLLA whereas the expectation measures (with 290

one exception intended for LLA) were intended for persons with TJA. Moreover, the Delphi 291

survey included “personal challenges associated with rehabilitation” and “cosmesis/appearance” 292

based on a study14 targeting PLLA. The other 13 relevant themes were derived from literature 293

targeting general surgical populations6, 8, 11 or TJA.12 294

Four new themes were added separately from the Delphi survey as a result of the Aim 2 295

literature review: sexual activity, sports and recreation/leisure activity, recovery time, and 296

employment/vocational activity. “Sexual functioning” was mentioned in a review8 as a potential 297

expectation theme for surgical populations but the investigator chose not to include it in the 298

Delphi survey. Only 3.7% of total items were indexed to “sexual activity.” The same review8 299

also suggested the theme “recovery/treatment outcome.” The Delphi survey shortened this theme 300

to “treatment outcome.” However, because only 5 expectation items (1%) used wording specific 301

to “recovery” or “recovery time,” keeping its original name, “recovery/treatment outcome,” 302

would have been reasonable. Under the name “recovery/treatment outcome,” the themes, 303

“recovery time” and “treatment outcome” would have been combined. No references6, 8, 11, 12, 14 304

described themes related to “sports and recreation” or “employment/vocational activity.” 305

Expectation Measurement Methods 306

Most frequently, expectations were measured according to “order of magnitude” (56%) 307

and “degree of importance” (40%), together accounting for 96% of all items (Figure 9). This 308

skewed distribution indicates a preference among existing measures for these two measurement 309

methods. Of the relevant themes, only “fears” did not use “order of magnitude” whereas, five 310

themes (pain, treatment outcome, fears, overall satisfaction with care, health-related quality of 311

life) did not use “degree of importance.” Thus the items indexed to both a relevant theme and 312

“order of magnitude” are likely the most readily available items to include in a PLLA measure. 313

Appendix B lists these items and their response options. 314

Recommendations for Future Studies 315

Subsequently, the Aim 2 review was used to make recommendations for future 316

measurement of expectations of persons with PLLA. The selected study48 separated expectations 317

and outcomes into levels using response options. “High” was defined by responses, “much less” 318

or “less,” for expected and actual levels of pain.48 For activities of daily living (ADLs) and sport 319

and recreation, “high” expected and actual levels of improvement were defined by responses, 320

“much better” or “better.”48 The study48 calculated statistical differences between high 321

expectations and high outcomes at three postoperative times. A less-than-significant difference 322

indicated that high expectations were met at a given time point. 323

We believe that shaping patient expectations realistically will increase the likelihood for 324

positive long-term outcomes for persons with PLLA. To test this hypothesis we could answer the 325

question, “Are realistic expectations more likely to be met as measured by actual postoperative 326

outcomes?” Although the study48 used an “E4/O4” comparison to investigate whether high 327

expectations were more likely to be met at different postoperative times, adapting this method 328

would facilitate answering the above question. In a future PLLA study, expectations could be 329

measured and categorized as high, moderate, and low and then categorized as realistic or 330

unrealistic within each level. Outcomes could be measured using complementary items and 331

similarly categorized as high, moderate, and low. At each level, realistic expectations (e.g. 332

realistic, moderate expectations) would be compared to outcomes at a level equal or higher than 333

expected (e.g. moderate or high outcomes). 334

Studies from the Part 2 review made expectation and outcome items complementary by 335

different means, such as modifying an expectation measure to measure outcomes or modifying 336

an outcome measure to measure expectations. While the selected study48 modified an existing 337

outcome measure, the investigator recommends creating an expectation measure and then 338

modifying its items to also measure postoperative outcomes. The latter method better aligns with 339

the hypothesis, which focuses on relating outcomes to expectations. Aim 2 review results may 340

guide distribution of themes across a future expectations measure. For example, the themes 341

favored in Figure 8 (physical functioning, return to normal activities, and pain) might represent a 342

larger proportion of items than other relevant themes. 343

Limitations 344

The limitations of this study primarily relate to the Delphi survey. First, panelists were 345

identified by convenience sampling, which increases likelihood that panelists were not true 346

“experts” on patient expectations. Free text responses to Question 1 indicated confusion about 347

the definitions presented from expectations literature and so Question 1 was excluded from 348

Round 2. Participants likely lacked sufficient familiarity with relevant literature to confidently 349

answer Question 1. This must be considered when interpreting responses to the remaining five 350

questions. Secondly, wording of survey questions may have been unclear. The participant who 351

withdrew indicated that they found the questions, “too ambiguous for me to respond with any 352

confidence.” Thirdly, small panel size was limiting (6 in Round 1 and 4 in Round 2); one 353

review18 suggested a minimum of 30 panelists. Finally, expectation measure items from Part 1 of 354

the literature review could not be indexed to the category “expectation feature” because 355

terminology (e.g. expectation features) used by the literature to describe patient expectations is 356

incompatible with wording used by existing expectation measures. This precluded comparison 357

between trends in existing items and the five consensus statements regarding expectation 358

features. 359

This last limitation raises the question as to whether a more exhaustive literature review 360

should have been conducted before the Delphi survey. Doing so would have prevented asking 361

questions about expectation features. In this project, the investigator compared “expert” opinions 362

on how patient expectations should be defined to how expectations have actually been defined by 363

existing expectation measures. It may have been better to first conduct the review to understand 364

how existing expectation measures have already defined expectations of persons with TJA; then, 365

employ the Delphi process to reach “expert” consensus on any areas that overlap with 366

expectations of persons with PLLA. Performing the review first also would have enabled the 367

panel to rate relevance of the four additional themes that arose from the review. However, these 368

additional themes arose from TJA expectation measures, so none may be relevant to persons 369

with PLLA. Had they been presented, the Delphi may or may not have resulted in the same 15 370

relevant themes. 371

Finally, it must be noted that the review was almost exclusively of literature intended for 372

the TJA population. Only one study13 used an expectation measure designed for the intended 373

population—PLLA. Moreover, the review was not exhaustive as only one database was searched 374

(PubMed). 375

CONCLUSIONS 376

While “patient expectations” remains to be definitively defined, this study demonstrated 377

that if a definition is to complement how existing expectation measures already define patient 378

expectations, it must contain two components: expectation themes and measurement methods. 379

Additionally, any future PLLA measures should represent relevant themes and employ the “order 380

of magnitude” measurement method. The overlap found in expectation themes between persons 381

with TJA and PLLA supports our rationale to model future expectation measurement for persons 382

with PLLA after existing TJA measurement. Using TJA literature, we recommend an adapted 383

methodology for future studies comparing expectations and outcomes in persons with PLLA. 384

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579

580

FIGURE CAPTIONS 581

582

Figure 1. Flowchart illustrating the process of participation in the Delphi survey. 583

584

Figure 2. Comparison between target distribution of panelist demographics and the actual 585

distributions achieved in Delphi survey Rounds 1 and 2. 586

587

Figure 3. Results of the Aim 2 literature review. 588

589

Figure 4. Frequency of the 20 original expectation themes as a percentage of the total items (N = 590

483 items). These 20 themes were included in the Delphi survey process. All but one of the items 591

are intended for use with total hip and knee arthroplasty populations (N = 482/483); the 592

exception is a single item (N= 1/483) intended for persons with lower limb amputation. 593

594

Figure 5. Frequency of four additional, new themes as a percentage of the total number of items 595

(N=483 items). These four new themes were identified and created separate to the Delphi survey 596

process. 597

598

Figure 6. Frequency of themes that reached consensus as part of the Aim 1 Delphi process, that 599

did not reach consensus, and that were identified as part of the review. The distribution of themes 600

is shown with percentages of total items (N=483 items). 601

602

Figure 7. Distribution of themes that reached consensus. Frequency of each relevant theme is 603

shown as a percentage of total items pertaining only to themes that reached consensus (N = 367). 604

Themes that represented 5% or less of the total items were collapsed into a single group. These 605

themes were the following: disability, complications of treatment, treatment outcome, fears, 606

overall satisfaction with care, health-related quality of life, and health improvement. 607

608

Figure 8. The distribution of measurement methods across all items. The frequency of each 609

measurement method is shown as a percentage of the total number of items (N = 483). 610

611

Figure 9. Frequency of each measurement method as a percentage of the items within each 612

expectation theme. The distribution of measurement methods is shown for each theme 613

individually. 614

Figure 1.

InvitedN = 12

DeclinedN = 1

Accepted N = 8

WithdrewN = 1

Participated in Round 1

N = 6

Confirmed submission &

Invited to Round 2N = 5

Participated in Round 2

N = 4

Confirmed submission

N = 2

Unable to confirm submission

N = 2

Did not participateN = 1

Unable to confirm submission

N = 1

Did not participateN = 1

No response N = 3

Figure 2.

0

1

2

3

PT CP LLA Physiatrist/Surgeon

Conf

irmed

Par

ticip

ants

(n)

Target Round 1 Round 2

Figure 3.

Initial search resultsN = 378

•Results from PubMed•Duplicates included

Relevant studiesN = 34

•Duplicates excluded•Reviewed title/abstract•Relevancy criteria:

•THA, TKA, or LLA•Mentioned

expectations

Relevant reference studies

N = 27

•Searched references from relevant studies

•Reviewed title/abstract•Relevancy criteria:

•Cited as source of expectations measure

Total relevant studies N = 61

Included in Part 1 analysisN = 50

•Reviewed full text•Inclusion criteria:

•THA, TKA, or LLA•Prospective or

retrospective•Measured preoperative

expectations

Included in Part 2 analysisN = 16

•Reviewed full text•Inclusion criteria:

•THA, TKA, or LLA•Prospective only•Relationship between

expectations and outcomes

Figure 4.

29.6

3.5

0

5.2

14.9

0.4

1.7

19.9

0

1.9

0

0.6

1.4

0

0.2

3.9

0.2

0.4

0

0

0 5 10 15 20 25 30 35

PF

MF*

CF*

FI

P

SL*

HI

N

C*

D

TE

TC

TO

R/S

F

S/C*

S

QOL

PC

C/A

Frequency (% of total items)

Expe

ctat

ion

Them

es

Key for Expectation Themes:

C/A = Cosmesis/appearance

PC = Personal challenges associated with rehabilitation

QOL = Health-related quality of life

S = Overall satisfaction with care

S/C = Social/cultural role

F = Fears

R/S = Risk/safety

TO = Treatment outcome

TC = Complications of treatment

TE = Treatment effectiveness

D = Disability

C = Coping

N = Return to normal activities

HI = Health improvement

SL = Sleep

P = Pain

FI = Functional independence

CF = Cognitive functioning

MF = Mental functioning

PF = Physical functioning

*These expectation themes did not reach consensus by the Delphi process

Figure 5.

2.7

1

9.7

3.7

0 2 4 6 8 10 12

E

R

S/R

SX

Frequency (% of total items)

Sugg

este

d Ad

ditio

nal T

hem

es

Key for Expectation Themes:

SX = Sexual activity

S/R = Sports and recreation/leisure activity

R = Recovery time

E = Employment/vocational activity

Figure 6.

Consensus75%

No consensus8%

Suggested additional17%

Figure 7.

PF39%

N26%

P20%

FI7%

D/TC/TO/F/S/QOL/HI8%Key for Expectation Themes:

C/A = Cosmesis/appearancePC = Personal challenges associated with rehabilitationQOL = Health-related quality of lifeS = Overall satisfaction with careF = FearsR/S = Risk/safetyTO = Treatment outcomeTC = Complications of treatmentTE = Treatment effectivenessD = DisabilityN = Return to normal activitiesHI = Health improvementP = PainFI = Functional independencePF = Physical functioning

Figure 8.

OM269, 56%

DI193, 40%

OE8, 1%

P8, 2% N/A

5, 1%

Key for Measurement Methods:

OM = Order of magnitudeDI = Degree of importance

P = ProbabilityOE = Open-ended

N/A = Not applicable

Figure 9.

5547

5265

6357

89

3314

47100100

5420

5550

4353

4832

10038

42

14

47

4680

4350

43

2

2

1

11

3329

1

1

33

1005

0 10 20 30 40 50 60 70 80 90 100

PFMF*CF*

FIP

SL*HIN

C*D

TETCTO

R/SF

S/C*S

QOLPC

C/AER

S/RSX

Frequency (% of items per theme)

Expe

ctat

ion

Them

e (in

clud

ing

addi

tiona

l sug

gest

ed th

emes

)

*These expectation themes did not reach consensus by the Delphi process

OM DI OE P N/A

Table 1. Inclusion and exclusion criteria for Parts 1 and 2 of Aim 2 literature review.

Part 1 Part 2 Inclusion Criteria

• Participants were persons with total hip arthroplasty (THA), total knee arthroplasty (TKA), or planned lower limb amputation (PLLA);

• Prospective or retrospective study design; • Measured preoperative expectations; • If retrospective, language within items still

captured preoperative expectations (as opposed to postoperative expectations).

• Participants were persons with total hip arthroplasty (THA), total knee arthroplasty (TKA), or planned lower limb amputation (PLLA);

• Prospective study design only; • Investigated (to any extent) the relationship

between “expectations” and “outcomes,” such that the following was true: o “Expectations” constituted an input

variable representing the patient’s preoperative perspective on future health status as a result of surgery.

o “Outcomes” constituted an output variable representing the patient’s postoperative perspective on current health status as a result of surgery.

• Health status referred to one or more of these domains5: o Current health state; o Health-related quality of life; and/or, o Satisfaction.

Exclusion Criteria

Whether prospective or retrospective, studies were excluded if language within items appeared to capture postoperative expectations.

Retrospective studies were excluded.

Table 2a. Responses to Question 2. Boldface values represent consensus (greater than or equal

to 70%).

Round 1 Round 2

Features to Include in Definition of Expectations

Yes (include this feature) Consensus Statement Yes

(agree)

No (do not

agree)

Anticipations 100 A definition of patient expectations should

include all of the following features: anticipations,

desires, and needs.

100 0 Desires 100 Needs 100 Beliefs 66.7

None of these features 0

Table 2b. Responses to Question 3. Boldface values represent consensus (greater than or equal

to 70%).

Round 1 Round 2

Measurement Method(s) for Each Feature

Anticipations Desires Needs Beliefs Consensus Statements

Yes (agree)

No (do not

agree)

Order of magnitude 50 33.33 50 40

“Anticipations” should be

measured in all the following

ways: order of magnitude, probability,

open-ended, and degree of importance.

100 0

Probability 66.67 33.33 83.33 40

Open-ended 66.67 66.67 33.33 40 “Desires” should be measured in all the following ways: order of

magnitude, probability,


100 0 Degree of

importance 16.67 16.67 33.33 20

None of these 0 0 0 20

“Needs” should be measured in all the following ways: order of

magnitude, probability,


100 0

Table 2c. Responses to Question 5. Boldface values represent consensus (greater than or equal to

70%).

Round 1 Round 2

Features that Can Likely Be Shaped

by Clinicians

Yes (this feature can be shaped) Consensus Statement Yes

(agree) No (do not

agree)

Anticipations 100 “Anticipations” and “needs” can be shaped or

influenced by discussion/communication

with a health care provider prior to surgical

treatment.

100 0 Desires 66.67 Needs 83.33 Beliefs 66.67

None of these 0

Table 2d. Responses to Question 6. Boldface values represent consensus (greater than or equal to 70%).

Round 1 Round 2 Expectation Themes of

Planned LLA Irrelevant Somewhat Irrelevant Neutral Somewhat

Relevant Relevant Consensus Statement Yes (agree)

No (do not agree)

Physical functioning 0 0 0 0 100 The following expectation themes are all relevant to persons with planned LLA:

• physical functioning • functional independence • pain • health improvement • return to normal activities • disability • treatment effectiveness • complications of

treatment • treatment outcome • risk/safety • fears • overall satisfaction with

care • health-related quality of

life • personal challenges

associated with rehabilitation

• cosmesis/appearance

100 0

Mental functioning 0 0 16.67 16.67 66.67 Cognitive functioning 0 0 16.67 33.33 50 Functional independence 0 0 0 0 100 Pain 0 0 0 16.67 83.33 Sleep 0 0 33.33 50 16.67 Health improvement 0 0 0 16.67 83.33 Return to normal activities 0 0 0 16.67 83.33 Coping 0 0 0 33.33 66.67 Disability 0 0 0 16.67 83.33 Treatment effectiveness 0 0 0 0 100 Complications of treatment 0 0 0 16.67 83.33 Treatment outcome 0 0 0 0 100 Risk/safety 0 0 0 0 100 Fears 0 0 0 0 100 Social/cultural role 0 0 0 33.33 66.67 Overall satisfaction with care 0 0 0 16.67 83.33

Health-related quality of life 0 0 0 0 100

Personal challenges associated with rehabilitation

0 0 0 0 100

Cosmesis/appearance 0 0 0 0 100

Table 3. Types of expectation variable, outcome variable, and comparisons.

Definitions

Types of Expectation

Variable

E1 Individual expectation item responses E2 Cumulative expectation score E3 Number of expectations held

E4 Level of expectations (e.g. high or low)

Types of Outcome Variable

O1 Individual outcome item responses O2 Cumulative outcome score

O3 Outcome improvement (i.e., change in outcome from baseline to postoperative time point)

O4 Level of outcomes (e.g. high or low)

Frequency (N = number of studies)

Studies

Types of Comparison

E1/O1 5 Brokelman 2008; Gonzalez 2010; Mannion 2009*; Nilsdotter 2009; Williams 2014

E1/O2 2 Engel 2004; Mahomed 2002 E1/O3 3 Judge 2011; Mannion 2009; Quintana 2009 E2/O2 2 Jones 2012; Palazzo 2014 E2/O3 1 Cross 2009 E2/O4 1 Palazzo 2014 E3/O1 1 Judge 2011 E3/O3 1 Cross 2009 E4/O2 3 Gandhi 2009; Lingard 2006; Mahomed 2002 E4/O3 3 Arden 2011; Gandhi 2009; Nilsdotter 2009

E4/O4 5 Arden 2011; Gandhi 2009; Lingard 2006; Nilsdotter 2009; Vissers 2010

APPENDIX A

APPENDIX B

Expectation Theme Item Reference Response

Format Response Options

PF Being able to walk without a limp

Adie 2011 5-point Likert scale

0=no improvement expected or not applicable; 1=slight improvement only; 2=mild improvement; 3=moderate improvement; 4=significant improvement

PF Improvement in walking



PF Be able to climb the stairs



PF Sitting Adie 2011 5-point Likert scale


PF Future walking ability

Eisler 2002

4-point Likert scale

Same as after the primary THA; very much improved; slightly improved; not altered

PF Improve ability to walk short distance (indoors, 1 block

Ghomrawi 2011


4=complete improvement or back to normal; 3= not back to normal but complete improvement; 2=not back to normal but a moderate amount of improvement; 1=not back to normal but little improvement; 0=this expectation does not apply to me/I do not have this expectation



PF Improve ability to walk medium distance (take a walk, <1mile)

Ghomrawi 2011



PF Improve ability to walk long distance (>1mile)

Ghomrawi 2011



PF Make knee or leg straight

Ghomrawi 2011



PF Improve ability to go up stairs

Ghomrawi 2011





PF Improve ability to go down stairs

Ghomrawi 2011



PF Improve ability to kneel

Ghomrawi 2011



PF Improve ability to squat

Ghomrawi 2011



PF Improve ability to change position (for example, go from sitting to standing or from standing to sitting)

Ghomrawi 2011





PF Improved ability to walk

Gonzalez 2010


No expectations; few expectations; some expectations; many expectations; very high expectations

PF Improve ability to walk

Groeneveld 2008


4=complete improvement or back to normal; 3= a lot of improvement; 2=a moderate amount of improvement; 1=a little improvement; 0=this expectation does not apply to me/I do not have this expectation


Groeneveld 2008




Groeneveld 2008




Groeneveld 2008






Groeneveld 2008




Groeneveld 2008




Groeneveld 2008



PF Stiffness Haddad 2001


Increasing severity from 1 to 5

PF Physical function Haddad 2001



PF Walking Haworth 1981


1=in house; 2=to garden/street; 3=100 yards; 4=1/4 mile; 5=1 mile



PF Get rid of limp Jourdan 2012


4=complete improvement or back to normal; 3= a lot of improvement; 2=a moderate amount of improvement; 1=a little improvement; 0=I do not have this expectation; NA = this expectation does not apply to me


Jourdan 2012



PF Improve ability to stand

Jourdan 2012



PF Improve ability to climb stairs

Jourdan 2012



PF Distance able to walk without support

Lingard 2006


>2 mi (>3.2 km); 1 to 2 mi (1.6 to 3.2 km); about 0.5 mi (0.8 km); only a few yards (meters)




Mancuso 2001

NA Short distance (indoors 1 block) OR medium distance (take a walk, less than 1 mile) OR long distance (more than 1 mile)

PF Get rid of limp Mancuso 2008




Mancuso 2008




Mancuso 2008




Mancuso 2008






Mancuso 2008




Mancuso 2008




Mancuso 2008




Mancuso 2008






Mancuso 2008




Mancuso 2008




Mancuso 2008



PF Distance you expect to be able to walk before the pain from your knee becomes severe (with or without a stick)

Moran 2003


1=no pain/>30min; 2=16 to 30 min; 3=5 to 15 min; 4=around the house only; 5=not at all-severe on walking

PF Ability to kneel down and get up again afterwards

Moran 2003


1=yes, easily; 2= with little difficulty; 3=with moderate difficulty; 4=with extreme difficulty; 5=no, impossible



PF Ability to walk down a flight of stairs

Moran 2003



PF Distance you expect to be able to walk before the pain from your hip becomes severe (with or without a stick)

Moran 2003


1=no pain/>30min; 2=16 to 30 min; 3=5 to 15 min; 4=around the house only; 5=not at all-severe on walking

PF Walking ability Nilsdotter 2009


Crutches: need for crutches or some other device to move more than a few steps; Indoors: able to walk indoors; <1km: able to walk indoors and less than 1km outdoors; >1km: able to walk more than 1 km; Unlimited: unlimited walking on even ground; Uneven terrain: unlimited walking on uneven terrain

PF Other symptoms Nilsdotter 2009


Much less to Much more

PF How functionally able do you think you will be 3 months after surgery?

Oettingen 2002


1=not at all to 5= fully



PF Walking Palazzo 2014



PF Standing Palazzo 2014



PF Limp Palazzo 2014



PF Climbing stairs Palazzo 2014





PF Get rid of limp Poultsides 2014




Poultsides 2014




Poultsides 2014




Poultsides 2014






Poultsides 2014




Poultsides 2014




Poultsides 2014




Poultsides 2014






Poultsides 2014




Poultsides 2014




Poultsides 2014



PF Get rid of limp Van den Akker-Scheek 2010





PF Improve ability to walk short distance

Van den Akker-Scheek 2010



PF Improve ability to walk medium distance




PF Improve ability to walk long distance










PF Improve ability to change position


















PF Improve ability to cut toenails




FI Walk without walking aids



FI Feel more independent



FI Remove the need for a cane, crutch or walker

Ghomrawi 2011




Groeneveld 2008





FI Remove need for cane or other assistive device

Jourdan 2012

5 point Likert


FI Walking aid required Lingard 2006

Multiple choice

None; Stick/cane; Crutches; Walker


Mancuso 2008




Mancuso 2008



FI Using a cane Palazzo 2014






Poultsides 2014




Poultsides 2014







FI Remove need for a cane or other assistive device




P Relief of pain during the day





P Relief of pain during the night



P Reduce requirements for pain medication



P How painful do you expect your hip to be when you are fully recovered from surgery?

Arden 2011


Not at all painful; slightly painful; very painful

P Future pain Eisler 2002


None at all; much less; slightly less; not altered

P Level of pain expected after surgery

Gandhi 2009


No pain; slightly painful; moderately painful; very painful; extremely painful

P Relief of pain Ghomrawi 2011



P Pain relief Gonzalez 2010





P Relieve pain Groeneveld 2008



P Pain Haddad 2001



P Relieve daytime pain

Jourdan 2012



P Relieve nighttime pain

Jourdan 2012



P How painful do you expect your hip to be when you are fully recovered from this surgery?

Katz 1995 3-point Likert scale

1=not at all painful; 2=slightly painful; 3=very painful



P Do you expect your joint replacement surgery will relieve your pain?

Koenen 2014


no, not at all = 0; yes, a little bit = 1; yes, somewhat = 2; yes, a moderate amount = 3; yes, a lot = 4

P Level of pain Lingard 2006


None; Slight; Moderate; Very severe

P How painful do you expect your hip/knee to be?

Mahomed 2002


Not at all OR slightly painful OR moderately painful OR very painful

P Relieve pain Mancuso 2001

N/A Relieve some pain OR relieve most pain OR relieve all pain

P Relieve pain Mancuso 2008




Mancuso 2008






Mancuso 2008



P How painful do you expect your hip to be when you are fully recovered from this surgery?

Mannion 2009


1=not at all painful; 2=slightly painful; 3=very painful

P Pain from your knee Moran 2003


1=None; 2=very mild; 3=mild; 4=moderate; 5=severe

P After a meal (sat at a table), pain level expected when standing up from a chair because of your knee

Moran 2003


1=Not at all painful; 2= slightly painful; 3=moderately painful; 4=very painful; 5=unbearable

P Be troubled by pain from your knee in bed at night

Moran 2003


1=no nights; 2=only 1 or 2 nights; 3=some nights; 4=most nights; 5= every night

P Experience pain from your knee that interferes with your usual work (including housework)

Moran 2003


1=not at all; 2=a little bit; 3=moderately; 4=greatly; 5=totally



P Pain from your hip Moran 2003


1=None; 2=very mild; 3=mild; 4=moderate; 5=severe

P After a meal (sat at a table), pain level expected when standing up from a chair because of your hip

Moran 2003


1=not at all painful; 2=slightly painful; 3=moderately painful; 4=very painful; 5=unbearable

P Experience pain from your hip that interferes with your usual work (including housework)

Moran 2003


1=not at all; 2=a little bit; 3=moderately; 4=greatly; 5=totally

P Be troubled by pain from your hip in bed at night

Moran 2003


1=no nights; 2=only 1 or 2 nights; 3=some nights; 4=most nights; 5= every night

P Experience sudden, severe pain - "shooting," "stabbing," or "spasms" - from the affected hip

Moran 2003


1=no days; 2=only 1 or 2 days; 3=some days; 4= most days; 5=every day

P Pain Muniesa 2010

Numerical rating scale

0=most intense pain to 50=absence of pain



P Do you expect your knee joint replacement surgery will relieve your knee pain?

Nakano 2013



P Pain Nilsdotter 2009


Much less to Much more


Noble 2012



P To what extent do you think you will be without pain 3 months after surgery?

Oettingen 2002


1=not at all to 5= fully

P Relieving day pain Palazzo 2014





P Relieving night pain Palazzo 2014



P Relieve pain Poultsides 2014




Poultsides 2014




Poultsides 2014






Scuderi 2012



P Pain Suda 2010 Visual analog scale (VAS)

Not specified

P Relief pain Van den Akker-Scheek 2010



P Relief of daytime pain




P Relief of pain that interferes with sleep




P Pain level Vissers 2010


1=not at all painful; 2=slightly painful; 3=moderately painful; 4=very painful



P On average, how much pain do you expect to have 4/12 months after your recovery?

Williams 2014

Numerical rating scale

0=no pain to 10=pain as bad as it can be

HI Eliminate need for medications

Jourdan 2012




Mancuso 2008



HI Using medication Palazzo 2014






Poultsides 2014







N Feel more normal Adie 2011 5-point Likert scale


N Performing usual occupation



N Using a bathtub Adie 2011 5-point Likert scale




N Driving Adie 2011 5-point Likert scale


N Using public transport



N Wearing shoes and socks



N Ability to perform his/her usual activities

Gandhi 2009


No limitations (able to perform high-impact activities such as running, doubles, tennis, or hiking); slightly limited or moderately limited (walking a distance of 1 hour or playing golf); very limited or totally limited (walking, maximum of 20 minutes)

N Improve ability to use public transportation or drive

Ghomrawi 2011





N Improve ability to perform daily activities (for example, daily routine, household chores)

Ghomrawi 2011



N Improved ability to perform daily activities

Gonzalez 2010




Groeneveld 2008




Groeneveld 2008



N Personal care Haworth 1981


1=toilet transfers; 2= car transfers; 3=bath transfers; 4= cutting toenails

N Domestic activities Haworth 1981


1=light housework; 2=local shopping; 3=all shopping; 4=heavy housework



N Improve ability to get in or out of a bed, chair, or car

Jourdan 2012



N Improve ability to perform daily activities around the home

Jourdan 2012



N Improve ability to perform daily activities away from the home

Jourdan 2012



N Improve ability to put on shoes and socks

Jourdan 2012





N Improve ability to cut toenails

Jourdan 2012



N Do you expect your surgery will help you carry out your normal activities of daily living?

Koenen 2014




Mancuso 2008




Mancuso 2008






Mancuso 2008



N Improve ability to perform daily activites around the home

Mancuso 2008



N Improve ability to perform daily activites away from the home

Mancuso 2008




Mancuso 2008






Mancuso 2008



N Difficulty washing and drying yourself (all over) because of your knee

Moran 2003


1=No trouble at all; 2=very little trouble; 3=moderate trouble; 4=extreme difficulty; 5=impossible to do

N Difficulty getting in and out of a car or using public transport because of your knee (whichever you tend to use)

Moran 2003



N Ability to do household shopping on your own

Moran 2003



N Difficulty washing and drying yourself (all over) because of your hip

Moran 2003





N Difficulty getting in and out of a car or using public transport because of your hip (whichever you tend to use)

Moran 2003



N Ability to put on a pair of socks, stockings or tights

Moran 2003



N Ability to do household shopping on your own

Moran 2003




Nakano 2013



N ADLs Nilsdotter 2009


Much better to much worse


Noble 2012





N getting in or out of bed, chair, car

Palazzo 2014



N Putting on shoes Palazzo 2014



N Cutting toe nails Palazzo 2014



N Indoor activities Palazzo 2014






Poultsides 2014




Poultsides 2014




Poultsides 2014



N Improve ability to perform daily activites around the home

Poultsides 2014






Poultsides 2014




Poultsides 2014




Poultsides 2014




Scuderi 2012





N Improve ability to use public transportation, drive




N Improve ability to perform daily activities




N Improve ability to get in or out of a bed, chair or car




N Improve ability to perform daily activities around the home














D How limited do you expect to be in your usual activities, when you are fully recovered from surgery?

Arden 2011


Not limited at all; slightly limited; moderately limited; greatly limited

D How limited do you expect to be in your usual activities, when you are fully recovered from this surgery?

Katz 1995 4-point Likert scale

1=not limited at all; 2=slightly limited; 3=moderately limited; 4=greatly limited

D How limited do you expect to be in your usual activities?

Mahomed 2002


Not at all limited OR slightly limited OR moderately limited OR very limited



D How limited do you expect to be in your usual activities, when you are fully recovered from this surgery?

Mannion 2009


1=not limited at all; 2=slightly limited; 3=moderately limited; 4=greatly limited

D Limp when walking, because of your knee

Moran 2003


1=rarely/never; 2=sometimes or just at first; 3=often, not just at first; 4=most of the time; 5=all of the time

D Limp when walking, because of your hip

Moran 2003



D Feel that your knee might suddenly "give way" or let you down

Moran 2003



D Limitations of ADL Vissers 2010


1=not at all limited; 2=slightly limited; 3= moderately limited; 4=very limited

TC Complications Venkataramanan 2006


No; Not sure; Yes

TO Overall success of TKA

Vissers 2010

Visual analog scale (VAS)

0=no success; 10=optimal success

S Expectation of satisfaction with surgery 1 year postoperative

Brokelman 2008

Visual analog scale (VAS)

0 to 100



QOL What change do you expect in your overall quality of life as a result of the surgery?

Engel 2004


No change; small change; moderate increase; significant increase

QOL Knee-related quality of life

Nilsdotter 2009


Much better to much worse

615

Relationship between Realistic Preoperative Expectations ... … · 1 ABSTRACT 2 Introduction: To...

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Transcript of Relationship between Realistic Preoperative Expectations ... … · 1 ABSTRACT 2 Introduction: To...