Functional Assessment Across Various Time Points Following Hip or Knee Arthroplasty: Exploring Patient-Centeredness of Outcome Measures

Abstract

Background: Although hip or knee arthroplasty is generally a successful intervention, it is documented that up to one-third of patients undergoing arthroplasty report suboptimal outcomes. The first step in accurately identifying patients experiencing or being at risk for poorer recovery and optimizing outcomes is selecting the appropriate outcome measures. An important factor in this selection process is the extent to which these measures reflect patients' perspectives. However, there is limited information on the degree to which existing outcome measures used to assess function after hip or knee arthroplasty align with patients' perspectives and needs. Objectives: The overarching objective is to contribute to improving outcomes following hip or knee arthroplasty. Specifically, this dissertation research aims to evaluate the patient-centeredness of outcome measures used to assess function following hip or knee arthroplasty. Methods: To meet this objective, I conducted seven research studies guided by the International Classification of Functioning, Disability, and Health (ICF) framework: (1) a narrative review of key findings related to managing poorer outcomes after hip or knee arthroplasty; (2) a cognitive interview with 18 patients who underwent hip or knee arthroplasty, evaluating a developed self-report questionnaire on functional priorities; (3) a systematic review and content analysis of 50 patient-reported outcome measures (PROMs) used to assess function after hip or knee arthroplasty; (4) a systematic review and content analysis of 28 performance-based tests (PBTs) used after hip or knee arthroplasty; (5) a survey of functional activities with patients who underwent hip or knee arthroplasty; (6) a patient-centered content validity analysis of 50 PROMs and 28 PBTs used after hip or knee arthroplasty; and (7) a scoping review of patient involvement in the development of 50 PROMs. Results: The first study provided a foundation for guiding the subsequent studies in this dissertation and highlighted that the initial step in optimizing outcomes after hip or knee arthroplasty is selecting appropriate patient-centered functional outcome measures. To achieve this, a questionnaire was first developed based on the activity and participation components of the ICF core set for osteoarthritis (OA) and validated through cognitive interviews with patients, which provided a basis for the subsequent studies. The third study provided a detailed content analysis of 50 PROMs by linking their items to the modified ICF OA core set. The findings revealed variability in the coverage of activity and participation categories across PROMs, with some categories being inadequately covered or infrequently addressed. Additionally, the results indicated that some PROM items addressed multiple concepts or used complex wording. In the fourth study, the ICF-based content analysis of 28 PBTs revealed that these tests covered 15 categories of the ICF OA core set but did not address 34 other categories. To evaluate how well these PROMs and PBTs align with patients' perspectives, the fifth study surveyed 632 patients, identifying 26 key activities (i.e., activities that patients deemed important and challenging) and 22 non-key activities (i.e., activities considered unimportant or not challenging). The findings showed that patients had different key activities at each time point, with a decline in the number of key activities over time. Mapping the results from studies 2 and 3 with study 5 revealed that none of the outcome measures fully captured the key activities at various stages of recovery. The results also showed that the coverage of key functional activities varied across outcome measures at different time points following hip or knee arthroplasty. In addition, PROMs had varying recall periods, with the previous week and four weeks being the most common. Finally, the last study revealed that approximately half of these PROMs did not involve patients in their development. This study demonstrated that various methods were employed to involve patients at different stages of the development process. Conclusions: The overall findings from this dissertation highlighted that the 78 PROMs and PBTs used after hip or knee arthroplasty do not fully capture the key activities that are important to patients at various stages of recovery. The results emphasized the need to address these deficiencies to more accurately capture patient-relevant activities and needs. This can be achieved by increasing patient involvement in the development of these measures, using robust methods for item or activity development, enhancing comprehensibility, and optimizing response options and recall periods. Addressing these gaps may involve developing new outcome measures or modifying and combining existing ones. In addition, researchers should consider the evolving nature of key activities following arthroplasty to ensure that outcome measures remain relevant throughout the recovery process.