From the Department of Physical Therapy, University of Alberta, Edmonton AB (Dr. Jones) and UT MD Anderson Cancer Center, Houston, TX (Dr. Suarez-Almazor).

Abstract

• Objective: To discuss patient expectations of total knee arthroplasty (TKA), instruments used to measure expectations, and the association between expectations, health outcomes, and satisfaction.
• Methods: Review of the literature.
• Results: TKA is an elective surgery for patients with persistent pain and disability caused by knee arthritis. Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status, employment status, and trust in physicians. Patients have high overall expectations for recovery, particularly for pain relief and walking. Surgeons’ expectations tend to be more optimistic than patients’, although a subset of patients may have unrealistically high expectations. Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are unwilling to proceed with surgery. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minority groups. Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain.
• Conclusion: A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. A core set of reliable and valid instruments to measure expectations may encourage their routine use in both clinical and research settings.

Key words: total knee arthroplasty; osteoarthritis; patient expectations; shared decision making; joint replacement.

Total knee arthroplasty (TKA) is an elective surgery for patients with persistent pain and disability caused by knee arthritis. It is viewed as an effective and cost-effective surgical treatment for end-stage osteoarthritis (OA) [1–4]. As the population ages and obesity rates steadily increase, so will the utilization rates for TKA, with projected demand in the United States expected to grow 673% by 2030 [5–7]. The key indicators for receiving primary TKA are end-stage OA and joint pain [8]. Although TKA is a surgical option when conservative management is exhausted, no consensus exists as to the severity of symptoms required to consider surgery [9]. Variation in the utilization of TKA exists with respect to gender, racial/ethnicity, hospital, and geography [10,11]. These differences cannot be explained by prevalence of arthritis or symptoms or by access to health care alone. Increasingly, studies have shown these variations are largely attributable to patients’ preferences, driven by their beliefs, concerns, familiarity with the procedure, and expectations, along with physician opinion [12]. While physician opinions and recommendations clearly influence patients’ decisions, they do so primarily by modulating patients’ beliefs and expectations.

Patient expectations, not only of the effectiveness of the procedure itself but also of the recovery process, influence the decision to undergo an elective surgery such as joint arthroplasty. Ideally, these expectations should be informed by evidence, but often, lack of knowledge, preconceived beliefs, and misconceptions can taint informed decision making. A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. Understanding patient expectations and factors that influence expectations provides a fuller appreciation of the outcomes that are meaningful to patients and can guide preoperative education and open dialogue with patients within a shared decision making model of care. In this paper, we discuss patient expectations of TKA, including expectations regarding outcomes and recovery, fulfillment of expectations, and the association of fulfilled expectations with satisfaction.

Measurement of Expectations

The construct of expectation is complex and situational. The ambiguity within the literature occurs most likely because expectations are multifaceted. Expectation involves the notion of expectancy, with respect to health care, that given events are likely to occur as a result of a medical procedure or treatment. This concept is in contrast to wants, which reflects a patient’s desire or wishes that an event will occur [13]. The term patient expectation, however, is commonly confused with patient preference or value. Preference implies a relative valuation or comparison by the patient and, unlike expectation, may not be explicitly expressed by the patient [13]. Different types of health care expectations exist that broadly relate to what patients expect regarding health care structure, process, and outcome [14].

Studies of patient expectations are diverse within the orthopedic research field and reflect differing theoretical underpinnings and lack of standardization. The lack of standardization makes measuring the complex concept of expectations challenging. While a number of conceptual models exist, Bowling and colleagues aptly recognize the multidimensionality of expectations and that no one conceptual model captures patient expectations [14]. The lack of standardization was noted in a systematic review by Haanstra and colleagues who found great variety in the definitions and measurements of expectations in studies examining their relationship with outcomes of total joint arthroplasty [15].

No gold standard measure exists for measuring patient expectations of orthopedic surgery. Zywiel’s systematic review [16] of 66 studies identified 7 validated instruments for measuring patient expectations for orthopedic surgery: of these, 2 were specific to TKA (Hospital for Special Surgery (HSS) Expectation Survey [17] and Expectation Domain of the New Knee Scoring System [18,19]), and 2 were generic to musculoskeletal conditions (Expectation domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments [20] and the Sunnybrook Surgery Expectation Survey [21]). A number of other measures used within the literature were identified; however, the psychometric properties for many of these measures were not reported and any evidence of testing and validation were lacking [16]. Some studies used a single question to measure expectations. As patient expectation is multi-dimensional, using a single item to evaluate expectations is problematic. Zywiel and others have called for a core set of reliable and valid instruments to measure expectations [14,22], which may encourage their routine use in both clinical and research settings.

Patients Expectations for TKA Recovery

Although patient concerns vary in terms of importance and severity [23], pain and physical limitations are primary concerns for patients seeking TKA. Patients have high overall expectations for recovery, particularly for pain relief and walking [24–32]. TKA is an elective surgical procedure that provides substantial pain relief and improvements in function and quality of life, with the largest gains seen within the first 6 months [33,34]. Both short-term and long-term effect sizes for pain relief and functional recovery are large, in excess of 1.0 [34]. Over 70% of patients undergoing TKA expect to be pain-free, and 35% expect to have no limitations with routine activities [24,28,31].

Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status [17], employment status, and trust in physicians [32,35]. There is, however, inconsistent evidence on associative preoperative factors of recovery expectations. While some evidence supports an association between higher expectations and younger age and greater preoperative functional limitation [26–28,32,36–38], others have reported no significant association with several preoperative factors including age, gender, and preoperative functional status [24,26,37]. Lower overall expectations [28] and lower expectations for pain relief [21] were also seen for patients with a greater number of comorbid conditions.

It may be that patients with high preoperative expectations are more optimistic, interpret their health-reported quality of life gains more liberally, and are more likely to adhere to rehabilitation treatment [24,25]. Optimism is a generalized expectancy of a positive outcome that is related to indicators of well-being [39]. Presurgical optimism was shown to be associated with less postsurgical pain and anxiety in patients undergoing total hip and knee arthroplasty [40].

In addition to general future-oriented constructs, such as optimism, treatment-specific psychological constructs, such as treatment credibility and treatment expectancy, are seen in patients with total joint arthroplasty. A strong but not redundant association is seen between treatment expectancy and treatment credibility, that is, expectations of a treatment may be related as to how credible the treatment outcomes appear [41,42]. Haanstra and colleagues advocate further clinical work to explore which factor predicts total joint arthroplasty outcomes so that patients who are at a higher risk of poor outcomes can be identified [42].

Others have recognized that perspectives and expectations of surgical outcomes differ between patient and surgeon [43–45]. Overall, surgeons’ expectations tend to be more optimistic than patients expectations of outcomes, although a subset of patients may have unrealistically high expectations [46]. Patients do not always realize that some of their expectations cannot be met by current orthopedic procedures, and this gap in understanding is an important source of discrepancies in expectations and patient dissatisfaction [46]. Ghomrawi and colleagues reported that approximately one-third of 205 patients undergoing primary TKA had higher expectations than their surgeons did. Being male and having lower preoperative pain was associated with having discordantly higher preoperative expectations [44]. For realistic expectations to be set, patients need accurate and understandable information about expected positive outcomes of surgery such as level of function and symptom relief as well as the risk of joint failure, adverse events, complications, and activity limitations. Although little work has explored the alignment of patient and surgeon’s expectations, setting realistic expectations may be aided by using a shared decision making approach that incorporates patient preferences and values, the best available evidence, and the surgeon’s expertise.

Expectations and Willingness to Undergo Surgery

Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are “unwilling” to proceed with surgery [47,48]. Willingness is a component of the medical decision making process and is influenced by preferences. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minor-ity groups [12,47–49]. Preference-sensitive medical decisions, such as whether or not to proceed with TKA, are related to patients’ attitudes and perceptions, which can be affected by sociocultural influences. In a cohort of 627 male patients with moderate to severe OA who were viewed as “good” candidates for total joint arthroplasty, more African Americans (24%) than Caucasian Americans (15%) had lower expectations for outcomes of surgery [35]. In particular, African Americans expressed concerns about postoperative pain and walking. Similar findings were also reported in another study in which minority patients were less likely to consider TKA [12]. Determinants of preferences were patients’ beliefs about the efficacy of the procedure and knowing others who had already undergone TKA [12]. Ibrahim and colleagues postulated that outcome expectations mediated or influenced the willingness to undergo total joint arthroplasty surgery [49]. Interventional work that built upon this premise suggested that willingness to proceed with TKA could be modified by educational interventions. In a randomized controlled trial of 639 African American patients attending Veteran’s Affairs primary clinics who received a decision aid with or without brief counseling, willingness to proceed with TKA increased and patient-provider communication improved among the patients who received any intervention [50]. Yet in another randomized trial involving African American patients who received care from an academic center, a combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients’ preferences toward joint replacement surgery for knee OA [51]. This led the authors to recommend further exploration of patients’ knowledge, beliefs, and attitudes regarding surgical treatments for OA.

Effect of Expectations on Health Outcomes and Satisfaction

Some evidence suggests that better outcomes are seen in patients with higher expectations of recovery and, in turn, expectations that are met influence patient satisfaction. A systematic review of several chronic conditions showed with consistency across studies that positive recovery expectations were associated with better health outcomes [22]. The effect size varied with the condition and measure; however, none of the 16 studies examined arthritis or joint arthroplasty. Conversely, a systematic review of 18 prospective longitudinal cohort studies examining the association between expectation and outcomes (ie, pain, function, stiffness, satisfaction, overall improvement) reported less than convincing evidence of an association between patient preoperative expectations and treatment outcomes for THA and TKA in terms of short- and long-term postoperative pain and functional outcomes [15]. No consistent associations were seen with adjusted analysis of patient expectations and pain or functional outcomes at greater than 6 weeks [15]. Inconsistencies seen among the reviewed articles may be related to a number of issues centred on terminology, construct, expectation measures, and confounding effects.

Although TKA is an effective surgical procedure with large gains reported, 14% to 25% participants report little or no symptom improvement and/or dissatisfaction up to 1 year after surgery [1,52–59]. In a study with 5 years of follow-up, a decline in the satisfaction rate was seen after 1 year, although this decline was seen more so with physical function than with pain [38]. Although dissatisfaction can be attributed to surgical complications, in many cases, no technical or medical reasons can be identified. In a subset of patients who received TKA, surgical intervention does not adequately address patients’ concerns of pain and activity limitation. To compound matters, fair agreement was reported between patient and surgeon regarding satisfaction at 6 and 12 months postoperative. Disagreement between the patient and surgeon was explained by unmet expectations and postoperative complications [60]. When there was discordance, more often than not patients were less satisfied with TKA outcomes than surgeons [60,61].

While several theories explain patient satisfaction [62–65], evidence from total joint arthroplasty studies support the concept that satisfaction is derived from fulfillment of expectations [17,52]. Preoperative expectations are not to be confused with postoperative fulfilment of expectations, which are reflective of whether expectations of treatment have been met. Satisfaction is a value judgment and can be viewed as an affective domain, whereas expectation is a cognitive domain [66]. Patient satisfaction is regarded as the extent of a person’s experience compared to their expectation. As with expectations, a number of theoretical constructs exist concerning patient satisfaction [14,67]. Many dimensions of satisfaction exist, with patient expectations being central to these constructs. Deviation from expectations, however, does not necessarily correspond to dissatisfaction [67].

Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain [33,38,52,55,56,68]. Greater preoperative pain, postoperative complications, lower 1-year WOMAC scores and functional limitations were associated with dissatisfied patients [38,52,53,59]. While no consistent associations were seen with preoperative expectations, consistent evidence has shown that fulfillment of expectations has an impact on satisfaction [31,36,52,58,69].

It should be acknowledged that the concept of fulfillment of expectations is not the same as satisfaction. A patient can be satisfied with TKA even though their expectations have not been met. The fulfillment of expectations is dependent upon the type of expectation and the postoperative time period. Fulfillment of expectations were seen with pain relief, function, walking and health status [25,31,70] while patients expectations were not always met with leisure activities [38].

Shared Decision Making

The shared decision making process, in which the patient and physician share responsibility and actively participate in the clinical decision making process [71], may help in ensuring that patients’ expectations are met. Shared decision making requires eliciting patients’ preferences and values, providing clear information on the processes that will occur during surgery, recovery, rehabilitation, and in the longer phase of recovery, and what realistic outcomes can be expected. While a more “paternalistic” approach predominated in earlier years, the current trends indicate greater patient involvement in decision making with the surgeon, with open discussion of patient goals and expectations [71]. This approach also aids patients in their preparation for the recovery and rehabilitation stages, which can be challenging, especially if they are unaware as to what to expect. Patient expectations are more likely to be met when there is shared decision making and patients have been given relevant information and understand what is a reasonable outcome. While a shared decision making approach is advocated within orthopedics [72], patient expectations are largely not measured in the clinical setting.

Patient education is an integral component of assisting patients to make informed decisions; however, it is unknown whether education alone can modify expectations. Educational approaches can include group classes, videos, and written materials [73]. Limited evidence from a randomized controlled trial suggests that preoperative expectations can be modified by preoperative education classes by decreasing the number of expectations and having more expectations in agreement with the surgeons’ expectations [29]. Mancuso and colleagues, who looked at whether a preoperative education session could modify expectations found that larger changes in expectations were seen with those patients who had greater baseline expectation scores, worse pain and function, and were older [29]. Others have also reported that preoperative education reduces anxiety by providing patients with an understanding of what to expect [74,75]. An assumption is that expectations can be changed by improving knowledge, which underscores the need for relevant meaningful education to increase knowledge and instill realistic expectations. Others have surmised there is a proportion of patients who will continue to have unexpectedly high unrealistic expectations regardless of educational session [31,37]. This would suggest that education is not the only approach to modify expectations but rather different strategies may need to be implemented for a certain subsets of patients with unrealistic expectations.

Conclusion

Patient expectation is an important element to be considered in shared clinical decision making, as it can influ-ence preferences and subsequent satisfaction. Patients considering TKA have specific needs and expectations that they presume will be addressed with the surgery. If these are realistic, they can be met, and will result in greater patient satisfaction and better ongoing adherence to health care recommendations [76]. While much work has been conducted in identifying which patient characteristics may influence health expectations, additional research is needed to further determine how to shape expectations within a realistic, achievable framework. While traditional patient education is an important element to enhance knowledge, the limited available evidence suggests it is not sufficiently effective on its own. Other strategies such as use of individualized decision aids, provision of peer support, and enhanced provider-patient communication have been effective in many areas of health care and warrant evaluation in this field.

Corresponding author: Allyson Jones, PhD, Rm 2-50, Corbett Hall, University of Alberta, Edmonton, Alberta Canada T6G 2G4, [email protected].

Financial disclosures: None.

Author contributions: conception and design, CAJ, MES; analysis and interpretation of data, MES; drafting of article, CAJ, MES; critical revision of the article, CAJ, MES; collection and assembly of data, CAJ.

From the Department of Physical Therapy, University of Alberta, Edmonton AB (Dr. Jones) and UT MD Anderson Cancer Center, Houston, TX (Dr. Suarez-Almazor).

Abstract

• Objective: To discuss patient expectations of total knee arthroplasty (TKA), instruments used to measure expectations, and the association between expectations, health outcomes, and satisfaction.
• Methods: Review of the literature.
• Results: TKA is an elective surgery for patients with persistent pain and disability caused by knee arthritis. Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status, employment status, and trust in physicians. Patients have high overall expectations for recovery, particularly for pain relief and walking. Surgeons’ expectations tend to be more optimistic than patients’, although a subset of patients may have unrealistically high expectations. Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are unwilling to proceed with surgery. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minority groups. Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain.
• Conclusion: A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. A core set of reliable and valid instruments to measure expectations may encourage their routine use in both clinical and research settings.

Key words: total knee arthroplasty; osteoarthritis; patient expectations; shared decision making; joint replacement.

Total knee arthroplasty (TKA) is an elective surgery for patients with persistent pain and disability caused by knee arthritis. It is viewed as an effective and cost-effective surgical treatment for end-stage osteoarthritis (OA) [1–4]. As the population ages and obesity rates steadily increase, so will the utilization rates for TKA, with projected demand in the United States expected to grow 673% by 2030 [5–7]. The key indicators for receiving primary TKA are end-stage OA and joint pain [8]. Although TKA is a surgical option when conservative management is exhausted, no consensus exists as to the severity of symptoms required to consider surgery [9]. Variation in the utilization of TKA exists with respect to gender, racial/ethnicity, hospital, and geography [10,11]. These differences cannot be explained by prevalence of arthritis or symptoms or by access to health care alone. Increasingly, studies have shown these variations are largely attributable to patients’ preferences, driven by their beliefs, concerns, familiarity with the procedure, and expectations, along with physician opinion [12]. While physician opinions and recommendations clearly influence patients’ decisions, they do so primarily by modulating patients’ beliefs and expectations.

Patient expectations, not only of the effectiveness of the procedure itself but also of the recovery process, influence the decision to undergo an elective surgery such as joint arthroplasty. Ideally, these expectations should be informed by evidence, but often, lack of knowledge, preconceived beliefs, and misconceptions can taint informed decision making. A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. Understanding patient expectations and factors that influence expectations provides a fuller appreciation of the outcomes that are meaningful to patients and can guide preoperative education and open dialogue with patients within a shared decision making model of care. In this paper, we discuss patient expectations of TKA, including expectations regarding outcomes and recovery, fulfillment of expectations, and the association of fulfilled expectations with satisfaction.

Measurement of Expectations

The construct of expectation is complex and situational. The ambiguity within the literature occurs most likely because expectations are multifaceted. Expectation involves the notion of expectancy, with respect to health care, that given events are likely to occur as a result of a medical procedure or treatment. This concept is in contrast to wants, which reflects a patient’s desire or wishes that an event will occur [13]. The term patient expectation, however, is commonly confused with patient preference or value. Preference implies a relative valuation or comparison by the patient and, unlike expectation, may not be explicitly expressed by the patient [13]. Different types of health care expectations exist that broadly relate to what patients expect regarding health care structure, process, and outcome [14].

Studies of patient expectations are diverse within the orthopedic research field and reflect differing theoretical underpinnings and lack of standardization. The lack of standardization makes measuring the complex concept of expectations challenging. While a number of conceptual models exist, Bowling and colleagues aptly recognize the multidimensionality of expectations and that no one conceptual model captures patient expectations [14]. The lack of standardization was noted in a systematic review by Haanstra and colleagues who found great variety in the definitions and measurements of expectations in studies examining their relationship with outcomes of total joint arthroplasty [15].

No gold standard measure exists for measuring patient expectations of orthopedic surgery. Zywiel’s systematic review [16] of 66 studies identified 7 validated instruments for measuring patient expectations for orthopedic surgery: of these, 2 were specific to TKA (Hospital for Special Surgery (HSS) Expectation Survey [17] and Expectation Domain of the New Knee Scoring System [18,19]), and 2 were generic to musculoskeletal conditions (Expectation domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments [20] and the Sunnybrook Surgery Expectation Survey [21]). A number of other measures used within the literature were identified; however, the psychometric properties for many of these measures were not reported and any evidence of testing and validation were lacking [16]. Some studies used a single question to measure expectations. As patient expectation is multi-dimensional, using a single item to evaluate expectations is problematic. Zywiel and others have called for a core set of reliable and valid instruments to measure expectations [14,22], which may encourage their routine use in both clinical and research settings.

Patients Expectations for TKA Recovery

Although patient concerns vary in terms of importance and severity [23], pain and physical limitations are primary concerns for patients seeking TKA. Patients have high overall expectations for recovery, particularly for pain relief and walking [24–32]. TKA is an elective surgical procedure that provides substantial pain relief and improvements in function and quality of life, with the largest gains seen within the first 6 months [33,34]. Both short-term and long-term effect sizes for pain relief and functional recovery are large, in excess of 1.0 [34]. Over 70% of patients undergoing TKA expect to be pain-free, and 35% expect to have no limitations with routine activities [24,28,31].

Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status [17], employment status, and trust in physicians [32,35]. There is, however, inconsistent evidence on associative preoperative factors of recovery expectations. While some evidence supports an association between higher expectations and younger age and greater preoperative functional limitation [26–28,32,36–38], others have reported no significant association with several preoperative factors including age, gender, and preoperative functional status [24,26,37]. Lower overall expectations [28] and lower expectations for pain relief [21] were also seen for patients with a greater number of comorbid conditions.

It may be that patients with high preoperative expectations are more optimistic, interpret their health-reported quality of life gains more liberally, and are more likely to adhere to rehabilitation treatment [24,25]. Optimism is a generalized expectancy of a positive outcome that is related to indicators of well-being [39]. Presurgical optimism was shown to be associated with less postsurgical pain and anxiety in patients undergoing total hip and knee arthroplasty [40].

In addition to general future-oriented constructs, such as optimism, treatment-specific psychological constructs, such as treatment credibility and treatment expectancy, are seen in patients with total joint arthroplasty. A strong but not redundant association is seen between treatment expectancy and treatment credibility, that is, expectations of a treatment may be related as to how credible the treatment outcomes appear [41,42]. Haanstra and colleagues advocate further clinical work to explore which factor predicts total joint arthroplasty outcomes so that patients who are at a higher risk of poor outcomes can be identified [42].

Others have recognized that perspectives and expectations of surgical outcomes differ between patient and surgeon [43–45]. Overall, surgeons’ expectations tend to be more optimistic than patients expectations of outcomes, although a subset of patients may have unrealistically high expectations [46]. Patients do not always realize that some of their expectations cannot be met by current orthopedic procedures, and this gap in understanding is an important source of discrepancies in expectations and patient dissatisfaction [46]. Ghomrawi and colleagues reported that approximately one-third of 205 patients undergoing primary TKA had higher expectations than their surgeons did. Being male and having lower preoperative pain was associated with having discordantly higher preoperative expectations [44]. For realistic expectations to be set, patients need accurate and understandable information about expected positive outcomes of surgery such as level of function and symptom relief as well as the risk of joint failure, adverse events, complications, and activity limitations. Although little work has explored the alignment of patient and surgeon’s expectations, setting realistic expectations may be aided by using a shared decision making approach that incorporates patient preferences and values, the best available evidence, and the surgeon’s expertise.

Expectations and Willingness to Undergo Surgery

Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are “unwilling” to proceed with surgery [47,48]. Willingness is a component of the medical decision making process and is influenced by preferences. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minor-ity groups [12,47–49]. Preference-sensitive medical decisions, such as whether or not to proceed with TKA, are related to patients’ attitudes and perceptions, which can be affected by sociocultural influences. In a cohort of 627 male patients with moderate to severe OA who were viewed as “good” candidates for total joint arthroplasty, more African Americans (24%) than Caucasian Americans (15%) had lower expectations for outcomes of surgery [35]. In particular, African Americans expressed concerns about postoperative pain and walking. Similar findings were also reported in another study in which minority patients were less likely to consider TKA [12]. Determinants of preferences were patients’ beliefs about the efficacy of the procedure and knowing others who had already undergone TKA [12]. Ibrahim and colleagues postulated that outcome expectations mediated or influenced the willingness to undergo total joint arthroplasty surgery [49]. Interventional work that built upon this premise suggested that willingness to proceed with TKA could be modified by educational interventions. In a randomized controlled trial of 639 African American patients attending Veteran’s Affairs primary clinics who received a decision aid with or without brief counseling, willingness to proceed with TKA increased and patient-provider communication improved among the patients who received any intervention [50]. Yet in another randomized trial involving African American patients who received care from an academic center, a combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients’ preferences toward joint replacement surgery for knee OA [51]. This led the authors to recommend further exploration of patients’ knowledge, beliefs, and attitudes regarding surgical treatments for OA.

Effect of Expectations on Health Outcomes and Satisfaction

Some evidence suggests that better outcomes are seen in patients with higher expectations of recovery and, in turn, expectations that are met influence patient satisfaction. A systematic review of several chronic conditions showed with consistency across studies that positive recovery expectations were associated with better health outcomes [22]. The effect size varied with the condition and measure; however, none of the 16 studies examined arthritis or joint arthroplasty. Conversely, a systematic review of 18 prospective longitudinal cohort studies examining the association between expectation and outcomes (ie, pain, function, stiffness, satisfaction, overall improvement) reported less than convincing evidence of an association between patient preoperative expectations and treatment outcomes for THA and TKA in terms of short- and long-term postoperative pain and functional outcomes [15]. No consistent associations were seen with adjusted analysis of patient expectations and pain or functional outcomes at greater than 6 weeks [15]. Inconsistencies seen among the reviewed articles may be related to a number of issues centred on terminology, construct, expectation measures, and confounding effects.

Although TKA is an effective surgical procedure with large gains reported, 14% to 25% participants report little or no symptom improvement and/or dissatisfaction up to 1 year after surgery [1,52–59]. In a study with 5 years of follow-up, a decline in the satisfaction rate was seen after 1 year, although this decline was seen more so with physical function than with pain [38]. Although dissatisfaction can be attributed to surgical complications, in many cases, no technical or medical reasons can be identified. In a subset of patients who received TKA, surgical intervention does not adequately address patients’ concerns of pain and activity limitation. To compound matters, fair agreement was reported between patient and surgeon regarding satisfaction at 6 and 12 months postoperative. Disagreement between the patient and surgeon was explained by unmet expectations and postoperative complications [60]. When there was discordance, more often than not patients were less satisfied with TKA outcomes than surgeons [60,61].

While several theories explain patient satisfaction [62–65], evidence from total joint arthroplasty studies support the concept that satisfaction is derived from fulfillment of expectations [17,52]. Preoperative expectations are not to be confused with postoperative fulfilment of expectations, which are reflective of whether expectations of treatment have been met. Satisfaction is a value judgment and can be viewed as an affective domain, whereas expectation is a cognitive domain [66]. Patient satisfaction is regarded as the extent of a person’s experience compared to their expectation. As with expectations, a number of theoretical constructs exist concerning patient satisfaction [14,67]. Many dimensions of satisfaction exist, with patient expectations being central to these constructs. Deviation from expectations, however, does not necessarily correspond to dissatisfaction [67].

Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain [33,38,52,55,56,68]. Greater preoperative pain, postoperative complications, lower 1-year WOMAC scores and functional limitations were associated with dissatisfied patients [38,52,53,59]. While no consistent associations were seen with preoperative expectations, consistent evidence has shown that fulfillment of expectations has an impact on satisfaction [31,36,52,58,69].

It should be acknowledged that the concept of fulfillment of expectations is not the same as satisfaction. A patient can be satisfied with TKA even though their expectations have not been met. The fulfillment of expectations is dependent upon the type of expectation and the postoperative time period. Fulfillment of expectations were seen with pain relief, function, walking and health status [25,31,70] while patients expectations were not always met with leisure activities [38].

Shared Decision Making

The shared decision making process, in which the patient and physician share responsibility and actively participate in the clinical decision making process [71], may help in ensuring that patients’ expectations are met. Shared decision making requires eliciting patients’ preferences and values, providing clear information on the processes that will occur during surgery, recovery, rehabilitation, and in the longer phase of recovery, and what realistic outcomes can be expected. While a more “paternalistic” approach predominated in earlier years, the current trends indicate greater patient involvement in decision making with the surgeon, with open discussion of patient goals and expectations [71]. This approach also aids patients in their preparation for the recovery and rehabilitation stages, which can be challenging, especially if they are unaware as to what to expect. Patient expectations are more likely to be met when there is shared decision making and patients have been given relevant information and understand what is a reasonable outcome. While a shared decision making approach is advocated within orthopedics [72], patient expectations are largely not measured in the clinical setting.

Patient education is an integral component of assisting patients to make informed decisions; however, it is unknown whether education alone can modify expectations. Educational approaches can include group classes, videos, and written materials [73]. Limited evidence from a randomized controlled trial suggests that preoperative expectations can be modified by preoperative education classes by decreasing the number of expectations and having more expectations in agreement with the surgeons’ expectations [29]. Mancuso and colleagues, who looked at whether a preoperative education session could modify expectations found that larger changes in expectations were seen with those patients who had greater baseline expectation scores, worse pain and function, and were older [29]. Others have also reported that preoperative education reduces anxiety by providing patients with an understanding of what to expect [74,75]. An assumption is that expectations can be changed by improving knowledge, which underscores the need for relevant meaningful education to increase knowledge and instill realistic expectations. Others have surmised there is a proportion of patients who will continue to have unexpectedly high unrealistic expectations regardless of educational session [31,37]. This would suggest that education is not the only approach to modify expectations but rather different strategies may need to be implemented for a certain subsets of patients with unrealistic expectations.

Conclusion

Patient expectation is an important element to be considered in shared clinical decision making, as it can influ-ence preferences and subsequent satisfaction. Patients considering TKA have specific needs and expectations that they presume will be addressed with the surgery. If these are realistic, they can be met, and will result in greater patient satisfaction and better ongoing adherence to health care recommendations [76]. While much work has been conducted in identifying which patient characteristics may influence health expectations, additional research is needed to further determine how to shape expectations within a realistic, achievable framework. While traditional patient education is an important element to enhance knowledge, the limited available evidence suggests it is not sufficiently effective on its own. Other strategies such as use of individualized decision aids, provision of peer support, and enhanced provider-patient communication have been effective in many areas of health care and warrant evaluation in this field.

Corresponding author: Allyson Jones, PhD, Rm 2-50, Corbett Hall, University of Alberta, Edmonton, Alberta Canada T6G 2G4, [email protected].

Financial disclosures: None.

Author contributions: conception and design, CAJ, MES; analysis and interpretation of data, MES; drafting of article, CAJ, MES; critical revision of the article, CAJ, MES; collection and assembly of data, CAJ.

From the Department of Physical Therapy, University of Alberta, Edmonton AB (Dr. Jones) and UT MD Anderson Cancer Center, Houston, TX (Dr. Suarez-Almazor).

Abstract

• Objective: To discuss patient expectations of total knee arthroplasty (TKA), instruments used to measure expectations, and the association between expectations, health outcomes, and satisfaction.
• Methods: Review of the literature.
• Results: TKA is an elective surgery for patients with persistent pain and disability caused by knee arthritis. Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status, employment status, and trust in physicians. Patients have high overall expectations for recovery, particularly for pain relief and walking. Surgeons’ expectations tend to be more optimistic than patients’, although a subset of patients may have unrealistically high expectations. Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are unwilling to proceed with surgery. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minority groups. Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain.
• Conclusion: A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. A core set of reliable and valid instruments to measure expectations may encourage their routine use in both clinical and research settings.

Key words: total knee arthroplasty; osteoarthritis; patient expectations; shared decision making; joint replacement.

Total knee arthroplasty (TKA) is an elective surgery for patients with persistent pain and disability caused by knee arthritis. It is viewed as an effective and cost-effective surgical treatment for end-stage osteoarthritis (OA) [1–4]. As the population ages and obesity rates steadily increase, so will the utilization rates for TKA, with projected demand in the United States expected to grow 673% by 2030 [5–7]. The key indicators for receiving primary TKA are end-stage OA and joint pain [8]. Although TKA is a surgical option when conservative management is exhausted, no consensus exists as to the severity of symptoms required to consider surgery [9]. Variation in the utilization of TKA exists with respect to gender, racial/ethnicity, hospital, and geography [10,11]. These differences cannot be explained by prevalence of arthritis or symptoms or by access to health care alone. Increasingly, studies have shown these variations are largely attributable to patients’ preferences, driven by their beliefs, concerns, familiarity with the procedure, and expectations, along with physician opinion [12]. While physician opinions and recommendations clearly influence patients’ decisions, they do so primarily by modulating patients’ beliefs and expectations.

Patient expectations, not only of the effectiveness of the procedure itself but also of the recovery process, influence the decision to undergo an elective surgery such as joint arthroplasty. Ideally, these expectations should be informed by evidence, but often, lack of knowledge, preconceived beliefs, and misconceptions can taint informed decision making. A better understanding of patient expectations of TKA and recovery can identify knowledge gaps, misconceptions, and communication barriers, and ultimately improve shared decision making. Understanding patient expectations and factors that influence expectations provides a fuller appreciation of the outcomes that are meaningful to patients and can guide preoperative education and open dialogue with patients within a shared decision making model of care. In this paper, we discuss patient expectations of TKA, including expectations regarding outcomes and recovery, fulfillment of expectations, and the association of fulfilled expectations with satisfaction.

Measurement of Expectations

The construct of expectation is complex and situational. The ambiguity within the literature occurs most likely because expectations are multifaceted. Expectation involves the notion of expectancy, with respect to health care, that given events are likely to occur as a result of a medical procedure or treatment. This concept is in contrast to wants, which reflects a patient’s desire or wishes that an event will occur [13]. The term patient expectation, however, is commonly confused with patient preference or value. Preference implies a relative valuation or comparison by the patient and, unlike expectation, may not be explicitly expressed by the patient [13]. Different types of health care expectations exist that broadly relate to what patients expect regarding health care structure, process, and outcome [14].

Studies of patient expectations are diverse within the orthopedic research field and reflect differing theoretical underpinnings and lack of standardization. The lack of standardization makes measuring the complex concept of expectations challenging. While a number of conceptual models exist, Bowling and colleagues aptly recognize the multidimensionality of expectations and that no one conceptual model captures patient expectations [14]. The lack of standardization was noted in a systematic review by Haanstra and colleagues who found great variety in the definitions and measurements of expectations in studies examining their relationship with outcomes of total joint arthroplasty [15].

No gold standard measure exists for measuring patient expectations of orthopedic surgery. Zywiel’s systematic review [16] of 66 studies identified 7 validated instruments for measuring patient expectations for orthopedic surgery: of these, 2 were specific to TKA (Hospital for Special Surgery (HSS) Expectation Survey [17] and Expectation Domain of the New Knee Scoring System [18,19]), and 2 were generic to musculoskeletal conditions (Expectation domain of the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments [20] and the Sunnybrook Surgery Expectation Survey [21]). A number of other measures used within the literature were identified; however, the psychometric properties for many of these measures were not reported and any evidence of testing and validation were lacking [16]. Some studies used a single question to measure expectations. As patient expectation is multi-dimensional, using a single item to evaluate expectations is problematic. Zywiel and others have called for a core set of reliable and valid instruments to measure expectations [14,22], which may encourage their routine use in both clinical and research settings.

Patients Expectations for TKA Recovery

Although patient concerns vary in terms of importance and severity [23], pain and physical limitations are primary concerns for patients seeking TKA. Patients have high overall expectations for recovery, particularly for pain relief and walking [24–32]. TKA is an elective surgical procedure that provides substantial pain relief and improvements in function and quality of life, with the largest gains seen within the first 6 months [33,34]. Both short-term and long-term effect sizes for pain relief and functional recovery are large, in excess of 1.0 [34]. Over 70% of patients undergoing TKA expect to be pain-free, and 35% expect to have no limitations with routine activities [24,28,31].

Expectations regarding the surgical procedure and recovery can vary by diagnosis, personal characteristics, functional status [17], employment status, and trust in physicians [32,35]. There is, however, inconsistent evidence on associative preoperative factors of recovery expectations. While some evidence supports an association between higher expectations and younger age and greater preoperative functional limitation [26–28,32,36–38], others have reported no significant association with several preoperative factors including age, gender, and preoperative functional status [24,26,37]. Lower overall expectations [28] and lower expectations for pain relief [21] were also seen for patients with a greater number of comorbid conditions.

It may be that patients with high preoperative expectations are more optimistic, interpret their health-reported quality of life gains more liberally, and are more likely to adhere to rehabilitation treatment [24,25]. Optimism is a generalized expectancy of a positive outcome that is related to indicators of well-being [39]. Presurgical optimism was shown to be associated with less postsurgical pain and anxiety in patients undergoing total hip and knee arthroplasty [40].

In addition to general future-oriented constructs, such as optimism, treatment-specific psychological constructs, such as treatment credibility and treatment expectancy, are seen in patients with total joint arthroplasty. A strong but not redundant association is seen between treatment expectancy and treatment credibility, that is, expectations of a treatment may be related as to how credible the treatment outcomes appear [41,42]. Haanstra and colleagues advocate further clinical work to explore which factor predicts total joint arthroplasty outcomes so that patients who are at a higher risk of poor outcomes can be identified [42].

Others have recognized that perspectives and expectations of surgical outcomes differ between patient and surgeon [43–45]. Overall, surgeons’ expectations tend to be more optimistic than patients expectations of outcomes, although a subset of patients may have unrealistically high expectations [46]. Patients do not always realize that some of their expectations cannot be met by current orthopedic procedures, and this gap in understanding is an important source of discrepancies in expectations and patient dissatisfaction [46]. Ghomrawi and colleagues reported that approximately one-third of 205 patients undergoing primary TKA had higher expectations than their surgeons did. Being male and having lower preoperative pain was associated with having discordantly higher preoperative expectations [44]. For realistic expectations to be set, patients need accurate and understandable information about expected positive outcomes of surgery such as level of function and symptom relief as well as the risk of joint failure, adverse events, complications, and activity limitations. Although little work has explored the alignment of patient and surgeon’s expectations, setting realistic expectations may be aided by using a shared decision making approach that incorporates patient preferences and values, the best available evidence, and the surgeon’s expertise.

Expectations and Willingness to Undergo Surgery

Although total joint replacement is an effective treatment for advanced arthritis, approximately 30% of potential candidates are “unwilling” to proceed with surgery [47,48]. Willingness is a component of the medical decision making process and is influenced by preferences. Potential surgical candidates unwilling to proceed with surgery tend to be older, female, and from ethnic minor-ity groups [12,47–49]. Preference-sensitive medical decisions, such as whether or not to proceed with TKA, are related to patients’ attitudes and perceptions, which can be affected by sociocultural influences. In a cohort of 627 male patients with moderate to severe OA who were viewed as “good” candidates for total joint arthroplasty, more African Americans (24%) than Caucasian Americans (15%) had lower expectations for outcomes of surgery [35]. In particular, African Americans expressed concerns about postoperative pain and walking. Similar findings were also reported in another study in which minority patients were less likely to consider TKA [12]. Determinants of preferences were patients’ beliefs about the efficacy of the procedure and knowing others who had already undergone TKA [12]. Ibrahim and colleagues postulated that outcome expectations mediated or influenced the willingness to undergo total joint arthroplasty surgery [49]. Interventional work that built upon this premise suggested that willingness to proceed with TKA could be modified by educational interventions. In a randomized controlled trial of 639 African American patients attending Veteran’s Affairs primary clinics who received a decision aid with or without brief counseling, willingness to proceed with TKA increased and patient-provider communication improved among the patients who received any intervention [50]. Yet in another randomized trial involving African American patients who received care from an academic center, a combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients’ preferences toward joint replacement surgery for knee OA [51]. This led the authors to recommend further exploration of patients’ knowledge, beliefs, and attitudes regarding surgical treatments for OA.

Effect of Expectations on Health Outcomes and Satisfaction

Some evidence suggests that better outcomes are seen in patients with higher expectations of recovery and, in turn, expectations that are met influence patient satisfaction. A systematic review of several chronic conditions showed with consistency across studies that positive recovery expectations were associated with better health outcomes [22]. The effect size varied with the condition and measure; however, none of the 16 studies examined arthritis or joint arthroplasty. Conversely, a systematic review of 18 prospective longitudinal cohort studies examining the association between expectation and outcomes (ie, pain, function, stiffness, satisfaction, overall improvement) reported less than convincing evidence of an association between patient preoperative expectations and treatment outcomes for THA and TKA in terms of short- and long-term postoperative pain and functional outcomes [15]. No consistent associations were seen with adjusted analysis of patient expectations and pain or functional outcomes at greater than 6 weeks [15]. Inconsistencies seen among the reviewed articles may be related to a number of issues centred on terminology, construct, expectation measures, and confounding effects.

Although TKA is an effective surgical procedure with large gains reported, 14% to 25% participants report little or no symptom improvement and/or dissatisfaction up to 1 year after surgery [1,52–59]. In a study with 5 years of follow-up, a decline in the satisfaction rate was seen after 1 year, although this decline was seen more so with physical function than with pain [38]. Although dissatisfaction can be attributed to surgical complications, in many cases, no technical or medical reasons can be identified. In a subset of patients who received TKA, surgical intervention does not adequately address patients’ concerns of pain and activity limitation. To compound matters, fair agreement was reported between patient and surgeon regarding satisfaction at 6 and 12 months postoperative. Disagreement between the patient and surgeon was explained by unmet expectations and postoperative complications [60]. When there was discordance, more often than not patients were less satisfied with TKA outcomes than surgeons [60,61].

While several theories explain patient satisfaction [62–65], evidence from total joint arthroplasty studies support the concept that satisfaction is derived from fulfillment of expectations [17,52]. Preoperative expectations are not to be confused with postoperative fulfilment of expectations, which are reflective of whether expectations of treatment have been met. Satisfaction is a value judgment and can be viewed as an affective domain, whereas expectation is a cognitive domain [66]. Patient satisfaction is regarded as the extent of a person’s experience compared to their expectation. As with expectations, a number of theoretical constructs exist concerning patient satisfaction [14,67]. Many dimensions of satisfaction exist, with patient expectations being central to these constructs. Deviation from expectations, however, does not necessarily correspond to dissatisfaction [67].

Several patient-related factors are associated with satisfaction with TKA, including primary diagnosis, preoperative pain and function, and mental health, including depression, but the relationships of satisfaction with gender, age, and comorbid conditions are less certain [33,38,52,55,56,68]. Greater preoperative pain, postoperative complications, lower 1-year WOMAC scores and functional limitations were associated with dissatisfied patients [38,52,53,59]. While no consistent associations were seen with preoperative expectations, consistent evidence has shown that fulfillment of expectations has an impact on satisfaction [31,36,52,58,69].

It should be acknowledged that the concept of fulfillment of expectations is not the same as satisfaction. A patient can be satisfied with TKA even though their expectations have not been met. The fulfillment of expectations is dependent upon the type of expectation and the postoperative time period. Fulfillment of expectations were seen with pain relief, function, walking and health status [25,31,70] while patients expectations were not always met with leisure activities [38].

Shared Decision Making

The shared decision making process, in which the patient and physician share responsibility and actively participate in the clinical decision making process [71], may help in ensuring that patients’ expectations are met. Shared decision making requires eliciting patients’ preferences and values, providing clear information on the processes that will occur during surgery, recovery, rehabilitation, and in the longer phase of recovery, and what realistic outcomes can be expected. While a more “paternalistic” approach predominated in earlier years, the current trends indicate greater patient involvement in decision making with the surgeon, with open discussion of patient goals and expectations [71]. This approach also aids patients in their preparation for the recovery and rehabilitation stages, which can be challenging, especially if they are unaware as to what to expect. Patient expectations are more likely to be met when there is shared decision making and patients have been given relevant information and understand what is a reasonable outcome. While a shared decision making approach is advocated within orthopedics [72], patient expectations are largely not measured in the clinical setting.

Patient education is an integral component of assisting patients to make informed decisions; however, it is unknown whether education alone can modify expectations. Educational approaches can include group classes, videos, and written materials [73]. Limited evidence from a randomized controlled trial suggests that preoperative expectations can be modified by preoperative education classes by decreasing the number of expectations and having more expectations in agreement with the surgeons’ expectations [29]. Mancuso and colleagues, who looked at whether a preoperative education session could modify expectations found that larger changes in expectations were seen with those patients who had greater baseline expectation scores, worse pain and function, and were older [29]. Others have also reported that preoperative education reduces anxiety by providing patients with an understanding of what to expect [74,75]. An assumption is that expectations can be changed by improving knowledge, which underscores the need for relevant meaningful education to increase knowledge and instill realistic expectations. Others have surmised there is a proportion of patients who will continue to have unexpectedly high unrealistic expectations regardless of educational session [31,37]. This would suggest that education is not the only approach to modify expectations but rather different strategies may need to be implemented for a certain subsets of patients with unrealistic expectations.

Conclusion

Patient expectation is an important element to be considered in shared clinical decision making, as it can influ-ence preferences and subsequent satisfaction. Patients considering TKA have specific needs and expectations that they presume will be addressed with the surgery. If these are realistic, they can be met, and will result in greater patient satisfaction and better ongoing adherence to health care recommendations [76]. While much work has been conducted in identifying which patient characteristics may influence health expectations, additional research is needed to further determine how to shape expectations within a realistic, achievable framework. While traditional patient education is an important element to enhance knowledge, the limited available evidence suggests it is not sufficiently effective on its own. Other strategies such as use of individualized decision aids, provision of peer support, and enhanced provider-patient communication have been effective in many areas of health care and warrant evaluation in this field.

Corresponding author: Allyson Jones, PhD, Rm 2-50, Corbett Hall, University of Alberta, Edmonton, Alberta Canada T6G 2G4, [email protected].

Financial disclosures: None.

Author contributions: conception and design, CAJ, MES; analysis and interpretation of data, MES; drafting of article, CAJ, MES; critical revision of the article, CAJ, MES; collection and assembly of data, CAJ.

Lifestyle modification, rather than hormone therapy, should form the basis for managing estrogen-depletion symptoms and associated clinical problems in breast cancer survivors, according to a review of available evidence.

The review, conducted by the writing group for the Endocrine Society’s guidelines on management of menopausal symptoms, was prompted by the paucity of both randomized controlled trials in breast cancer survivors with estrogen deficiency issues and guidelines that sufficiently focus on treatment of this subgroup of women.

[email protected]

Lifestyle modification, rather than hormone therapy, should form the basis for managing estrogen-depletion symptoms and associated clinical problems in breast cancer survivors, according to a review of available evidence.

The review, conducted by the writing group for the Endocrine Society’s guidelines on management of menopausal symptoms, was prompted by the paucity of both randomized controlled trials in breast cancer survivors with estrogen deficiency issues and guidelines that sufficiently focus on treatment of this subgroup of women.

[email protected]

Lifestyle modification, rather than hormone therapy, should form the basis for managing estrogen-depletion symptoms and associated clinical problems in breast cancer survivors, according to a review of available evidence.

The review, conducted by the writing group for the Endocrine Society’s guidelines on management of menopausal symptoms, was prompted by the paucity of both randomized controlled trials in breast cancer survivors with estrogen deficiency issues and guidelines that sufficiently focus on treatment of this subgroup of women.

[email protected]

MADRID – Is there a need for an enterovirus-A71 vaccine?

This is a new question for North American and European physicians, but not so new in Asia.

“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Copyright MidgleyDJ/Wikimedia Commons

[email protected]


 

MADRID – Is there a need for an enterovirus-A71 vaccine?

This is a new question for North American and European physicians, but not so new in Asia.

“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Copyright MidgleyDJ/Wikimedia Commons

[email protected]


 

MADRID – Is there a need for an enterovirus-A71 vaccine?

This is a new question for North American and European physicians, but not so new in Asia.

“China says yes, with more than 15 million cases of hand, foot, and mouth disease resulting in 3,500 deaths since surveillance started in 2009,” Heli Harvala, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.

Copyright MidgleyDJ/Wikimedia Commons

[email protected]


 

Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”

The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.

The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.

The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.

Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”

The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.

The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.

The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.

Following the directive of the “Military Service by Transgender Individuals” Presidential Memorandum to reinstitute a ban on service for transgender service members, the Secretary of Defense has called for a new study of the impact of transgender service members on “military readiness, lethality, and unit cohesion, with due regard for budgetary constraints and consistent with applicable law.” Secretary of Defense Jim Mattis announced that he will “establish a panel of experts serving within the Departments of Defense and Homeland Security to provide advice and recommendations on the implementation of the president’s direction.”

The study follows on the heels of a July 2016 study issued by the RAND Corporation, which found that there are between 1,300 to 6,600 transgender active duty service members. According to the study, the “costs of gender transition-related health care are relatively low” and they had a “minimal” impact on force readiness.

The new study is due to President Trump by February 21, 2018 and is required to include a plan for implementing the ban. The potential ban on transgender service members is still set to go into effect March 23, 2018. However, there is some disagreement over whether the Presidential Memorandum leave the DoD with latitude to protect currently serving transgender service members or not.

The expected health care costs associated with transgender service members remains a significant factor in the policy decision. The RAND study estimated that health care costs would increase by between $2.4 million and $8.4 million annually with transgender service members out of an estimated $6.2 billion spent on active component health care spending, which would represent a 0.04% to 0.13% of the budget.

When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.

“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”

• Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
• Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
• Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
• Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
• If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”

[email protected]

When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.

“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”

• Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
• Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
• Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
• Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
• If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”

[email protected]

When Jennifer Gunter, MD, learned that Marie Claire magazine published an article suggesting that the recent solar eclipse affected menstrual cycles, she turned to social media to dismantle that assertion.

“If the new moon were associated with menstruation, then all women all over the world would be menstruating at the same time,” Dr. Gunter wrote in an Aug. 21, 2017 entry on her personal blog, which includes the slogan “Wielding the Lasso of Truth.” “Have none of these people ever considered that? Maybe that happens in the “Mists of Avalon,” but it doesn’t happen on Earth.”

• Be HIPAA compliant. “I don’t think I’ve ever used my work day to inform what I write about because there’s so much going on in the news,” she said. “You have to be HIPAA compliant because your patients may be following you online. In many ways, I hope that people I’m going to care for do read some of the things that I put out there because I’m trying to give good health information.”
• Be authentic. “When people meet me and have probably read some of my tweets and have heard me talk, they say they can match the voice with the person,” Dr. Gunter said. “People can tell when you’re not being authentic. That doesn’t work for me. I don’t have time to invent another persona!”
• Share articles you think are worthwhile. “If I have a friend who is in the tech industry, and if he posts an article on that topic, I figure he curated that, so maybe I’ll read it,” she said. “Likewise, if you’re a doctor and you have people following you on Facebook who are not physicians, they might say, ‘My friend who I went to high school with who’s a doctor thinks this New York Times article is worth reading. Maybe I should read it.’ People can lurk and share things, and that helps. I follow lots of doctors on Twitter that I don’t regularly engage with, but they post articles, and I’ll read them.”
• Make it clear who you’re speaking for. Are you speaking for your employer or for yourself? Are you giving medical advice, or is the content your opinion only? Include an appropriate disclaimer in your profile. Dr. Gunter’s Twitter profile reads: “Appropriately Confident OB/GYN, Canadian Spice, Sexpert, Lasso of Truth, Pegasister, Not medical advice, I speak for no one but me.”
• If you post regularly, expect criticism at some point. “If social media is not for you, you shouldn’t do it,” Dr. Gunter said. “But if you have a small Facebook account, why not share some good quality articles that you found interesting? You’d be surprised. What you might think is a throwaway message might be of real help to someone who doesn’t practice medicine. There’s a real hunger for good quality curated information.”

[email protected]

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

You probably aren’t surprised to learn that the jobless rate for young people aged 16-24 years has fallen to the lowest rate recorded since 1969. Those “Hiring” signs you see in every storefront tell the story. Although the jobless rate for young people is still twice that for adults, clearly there are jobs out there.

However, it appears that there are fewer young people looking for those jobs. In fact, the decline in what is referred to as the “labor force participation rate” is down significantly to 60.6% from a high point of 77.5% in 1989 (Summer Youth Unemployment Falls to Lowest Level Since 1969, by Eric Morath. Wall Street Journal. 2017 Aug 17).

Koji_Ishii/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.

People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.

[email protected]

The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.

People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.

[email protected]

The Sinai Robotic Surgery Trial in HPV Positive Oropharyngeal Squamous Cell Carcinoma is an interventional trial currently recruiting patients with early to intermediate stage HPVOPC.

People with HPVOPC are generally curable, are young, and will live for extended periods of time, and are also at high risk for long-term toxicity and morbidity from chemotherapy and radiation. The study will explore the necessity of additional intervention in HPVOPC after surgery, and it is estimated that more than half of patients will not require additional therapy.

[email protected]

BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.

The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.

Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.

The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.

Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – Catheter ablation of symptomatic atrial fibrillation produced significantly better quality of life after 12 months than did continued treatment with antiarrhythmic drugs in a randomized, multicenter trial with 155 patients who had a history of failed drug treatment.

The trial was notable as the first prospective comparison of atrial fibrillation (AF) management by ablation with drug treatment to use quality of life as the primary efficacy endpoint. Such a quality of life–oriented assessment has been lacking “even though the main indication for ablation is symptom relief,” Carina Blomström-Lundqvist, MD, said at the annual congress of the European Society of Cardiology.

Clinicians have traditionally measured residual or recurrent AF after treatment with a periodic ECG to see whether patients experience AF episodes that last at least 30 seconds, but this is “hardly a measure of successful treatment,” said Dr. Blomström-Lundqvist, an electrophysiologist at the University Hospital in Uppsala, Sweden.

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

I read with interest the article "Pronator Teres Myotendinous Tear" by Drs. Qayyum, Villacis, and Jobin (Am J Orthop. 2017;46(2):E105-E107), and I commend the authors for their interesting exploration of this unusual injury.

I would like to note that this pathology was previously reported by our group in 2015.¹ We now have a 2-year follow-up on this patient, and he has remained asymptomatic since his return to golf. Since this article was published, we have been contacted by 3 patients (one of whom is a radiologist who interpreted his own magnetic resonance imaging) describing similar mechanisms of injury, symptoms, imaging findings, and recovery with nonoperative management. This suggests that pronator teres rupture may have been previously unrecognized or underreported.

It is interesting that this patient was injured when his club stuck in the ground while our patient reported taking only a small divot during his injury. From these differing mechanisms it is unclear whether forceful contraction or sudden loading is the largest risk factor for obtaining this injury, and this could be a point for further research. As awareness of this injury pattern spreads, we look forward to seeing larger series and establishing the success rate of nonoperative treatment and the risk factors for its failure.

Brooks W. Ficke, MD

Brent A. Ponce, MD

Birmingham, AL

Authors' Response

We appreciate Dr. Ficke’s comments regarding his experience treating pronator teres injuries and agree that they are likely under-recognized and possibly underreported. We are uncertain which mechanisms during the golf swing strains the pronator teres to the point of injury, but it may be a combination of muscular fatigue, forceful contraction, and sudden resistance to concentric loading during the club striking the ground. In our experience, these injuries do appear to heal without observable deficit. Our patient is back golfing regularly without any arm symptoms and actually had an improvement in his golf handicap this season.

Charles M. Jobin, MD

Usama Qayyum, MBBS

Diego Villacis, MD

New York, NY

Study Overview

Objective. To explore the views of general practice staff on managing childhood obesity in primary care.

Design. Qualitative study.

Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.

Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.

Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.

Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.

Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services

Commentary

The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].

Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.

In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.

Applications for Clinical Practice

Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.

—Katrina F. Mateo, MPH

Study Overview

Objective. To explore the views of general practice staff on managing childhood obesity in primary care.

Design. Qualitative study.

Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.

Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.

Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.

Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.

Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services

Commentary

The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].

Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.

In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.

Applications for Clinical Practice

Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.

—Katrina F. Mateo, MPH

Study Overview

Objective. To explore the views of general practice staff on managing childhood obesity in primary care.

Design. Qualitative study.

Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.

Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.

Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.

Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.

Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services

Commentary

The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status [11]. Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity [12].

Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.

In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.

Applications for Clinical Practice

Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.

—Katrina F. Mateo, MPH