Determining Appropriateness of Total Joint Arthroplasty for Hip and Knee Osteoarthritis: Multi-methods Studies

Abstract

Background. Around 25-45% of elective total joint arthroplasty (TJA) for primary hip and knee osteoarthritis (OA) are of questionable appropriateness. -- Objective. To examine how appropriateness of elective TJA for hip and knee OA is determined. -- Methods and results. Multi-methods studies guided by the Knowledge-To-Action (KTA) framework and the six Hawker appropriateness criteria for TJA. Study 1 was an interpretive descriptive study exploring barriers and facilitators to using the Hawker appropriateness criteria for adults with knee OA. Nine semi-structured interviews with healthcare professionals and 14 with adults with a TKA revealed: a) 15 barriers (including difficulties in using criteria, lack of accessible conservative treatments, unreceptivity to practice change, clinical judgement limited to OA severity and age, patients receiving information after the decision is made); and b) one facilitator (providing research evidence to obtaining healthcare team buy-in). Study 2 was a systematic review identifying and appraising instruments to assess elective TJA appropriateness for adults with hip and knee OA. None of the 55 instruments met all the Hawker appropriateness criteria; the most included criteria were OA impact on quality of life and evidence of OA while the least included were trial of conservative treatments and elements of shared decision-making. There was limited evidence on psychometric properties. Study 3 was an environmental scan of online Canadian resources for adults with hip or knee OA considering TJA and healthcare professionals participating in the decision. The 73 patient resources were understandable for diverse health literacy levels, but only four were patient decisions aids. Thirteen healthcare professional resources typically recognized OA impact on quality of life, evidence of OA, trial of conservative treatments, and did not discuss elements of shared decision-making. -- Conclusion. When determining appropriateness of elective TJA for primary hip and knee OA, clinical practice and instruments typically focus on OA symptoms negatively impacting quality of life and radiographic evidence of OA, while trial of conservative treatments is less reported. The appropriateness decision-making process poorly acknowledges or supports patient preferences (e.g., shared decision-making). Appropriateness of elective TJA needs to be reconsidered and conceptualized in a way that supports early conservative treatments and patient-centred care.