Visual Aids Help Patients Understand Risk in Knee Replacement Surgery

Today, CreakyJoints, a Global Healthy Living Foundation community, announced the publication of The Impact of Information Presentation Format on Preference for Total Knee Replacement Surgery, in Arthritis Care & Research, an official journal of the American College of Rheumatology and the Association of Rheumatology Health Professionals. The study found that among patients without an existing strong preference for total knee replacement (TKR) surgery, visual aids to explain procedural risks help patients make a decision about TKR. Of four methods tested, participants exposed to images or a numerical, graphical spinner had stronger preferences for TKR (after controlling for baseline preferences) compared to those viewing the numbers only format (mean differences all p < 0.05).

The vast majority of people who undergo total knee replacement surgery have high satisfaction following the procedure; however, the decision to undergo major surgery is complicated when a patient either underestimates the potential benefits or overestimates their risk for complications, stated Liana Fraenkel, MD, MPH, Yale School of Medicine and lead investigator of the study. This study suggests there is value in developing visual decision-making tools that help patients better understand the benefits and risks of total knee replacement surgery to make choices about their care in consultation with their physician.

Pictures and Graphics Increase Knowledge and Preference in TKR

Recruited via email from the CreakyJoints member database as well as the CreakyJoints Facebook page, English speaking participants age 50 and older, living in the U.S., with self-reported physician diagnosis of rheumatoid, psoriatic and/or osteoarthritis involving one or both knees, and had not had previous total hip or knee replacement surgery were eligible for the study (n=648). At study initiation, each participant read a brief paragraph with numeric information only, about the possible outcomes of TKR surgery. They were presented with three options regarding their chance of different outcomes including:

  • Most patients (about 42 in 50) do great. They have significant pain relief and are very satisfied with the surgery. These patients would have the surgery again without hesitation.
  • Some patients (about 7 in 50) dont do as well as they expected. They continue to have a fair amount of pain and are not very satisfied with the surgery. They dont think they would have this surgery again if they had bad arthritis in their other knee.
  • A few patients (about 1 in 50) have a serious complication after the surgery (such as an infection in the replaced knee). These patients regret having had the surgery.

Study participants were then randomized into four groups who reviewed outcome risk information by: 1) numeric only, 2) numeric with an icon array (IA), which depicted people who do great in blue, people who dont do as well as expected in orange, and people who have a serious complication in black; 3) numeric with a set of 50 images depicting happy and unhappy patients (sorted randomly for each person); and, 4) numeric with a functional spinner, programmed to rotate with a limited-range, randomly generated, initial speed after being clicked on by the participant. Preference and knowledge of risk for TKR were then tested in all participants.

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After controlling for baseline preference, preferences for TKR were higher in the IA [LS mean (SE) = 7.17 (0.10), p= 0.0002], images [LS mean (SE) = 7.14 (0.10), p= 0.0005] and spinner groups [LS mean (SE) = 7.19 (0.10), p= 0.0001], compared to the numbers only format [LS mean (SE) = 6.66 (0.10)]. Results remained unchanged after also controlling for age, insurance (private vs other), knowing someone who did poorly after TKR, and knee pain. No significant differences in preferences were observed across formats for participants with an uncertain or very strong preference for TKR at baseline (Table 2).

Interestingly, the information format also influenced participants knowledge (F= 13.62, p < 0.0001) of the risk of different outcomes for TKR (remembering the actual risk as presented in numeric form). The mean (SD) knowledge score (possible range 0 to 3) was higher in the IA group [2.0 (1.1)] compared to all other formats [numeric= 1.4 (1.2), images= 1.4 (1.1), spinner= 1.3 (1.1)].

We recently completed a qualitative study of people with arthritis considering arthroplasty that found patients lacked information about various decisions related to their joint replacement, including timing of surgery, choice of surgeon, surgical site, and implant device, stated W. Benjamin Nowell, Ph.D., Director of Patient-Centered Research at CreakyJoints and study coauthor. At CreakyJoints, we want patients to understand the decisions that are being made about their care and to play a central role in making those decisions. This study confirms that visual decision aids can help patients to understand their risk of a less than ideal outcome, thereby allowing them to make informed decisions about TKR.

The authors concluded that further research is required to examine whether these tools increase the accuracy of patients expectations in clinical practice.

About CreakyJoints

CreakyJoints is a digital community for millions of arthritis patients and caregivers worldwide who seek education, support, advocacy, and patient-centered research. We represent patients through our popular social media channels, our website www.CreakyJoints.org, and the 50-State Network, which includes more than 1,200 trained volunteer patient activists.

As part of the Global Healthy Living Foundation, CreakyJoints also has a patient-reported outcomes registry called ArthritisPower with nearly 18,000 consented arthritis patients who track their disease while volunteering to participate in longitudinal and observational research. CreakyJoints also publishes the popular Raising the Voice of Patients series, which are downloadable patient-centered navigational tools for managing chronic illness. For more information and to become a member (for free), visit www.CreakyJoints.org. To participate in our patient-centered research program, visit www.ArthritisPower.org.

Jessica Daitch
Phone: 917-816-6712
Email: [email protected]