A research agenda to improve patients’ experience of knee replacement surgery: a patient-oriented modified Delphi study of patients of South Asian origin in British Columbia

Stirling Bryan; Laurie J. Goldsmith; Nitya Suryaprakash; Richard Sawatzky; Marilyn Mulldoon; Moira Le Mercier; David Moorthy; Rajiv Gandhi; Satwinder Kaur Bains; Linda C. Li; Mary Doyle-Waters; Sean Brown

doi:10.9778/cmajo.20190128

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Figure 1:
Sample Delphi question from the second-round survey. The research topic for this question was information on lifestyle changes (e.g., weight loss, diet, exercise) to prevent or delay osteoarthritis.

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Table 1:

Patient research priorities elicited from the focus group discussion

Research theme	Research topics
Avoiding knee replacement surgery	Information on lifestyle changes (e.g., weight loss, diet, exercise) to prevent or delay osteoarthritis
	Improving other surgical techniques (e.g., arthroscopy) to avoid or delay need for knee replacement surgery
	Managing knee symptoms (e.g., use of pain medication) to avoid or delay need for knee replacement surgery
Preparing for and deciding when to have knee replacement surgery	Understanding differences between patient and surgeon views on the right time for knee replacement surgery
	Improving wait times for surgery
	Effectively managing knee pain before surgery (e.g., medication, complementary and alternative medicine such as massage, homeopathy, diet)
	Information on lifestyle changes (e.g., weight loss, diet, exercise) before surgery to improve recovery after surgery
	Improving patient understanding of what to expect during and after surgery
	Providing emotional and psychological support to patients before surgery from other patients
	Providing emotional and psychological support to patients before surgery from professional counsellors
Knee implants	Improving knee implants that allow for kneeling, squatting and walking downhill
Surgical cuts	Improving surgical practices (e.g., stitching) for best healing and scar minimization
	Understanding the role of genetics in surgical scar formations
Recovery in hospital	Managing other illnesses while in hospital including medication interaction
	Promoting respectful behaviour between patients and clinicians in clinical settings
	Improving practices for physiotherapy after surgery
	Understanding differences between the patient and clinician views on the right time to discharge from the hospital
	Effectiveness of discharge to a rehabilitation hospital before being sent home
Recovery longer term (i.e., after hospital discharge)	Integrating family doctors into recovery after surgery at the hospital and after discharge from hospital
	Exploring the best role of the surgeon after hospital discharge
	Effective use of pain medication after hospital discharge
	Effective support from the health care system after surgery
	Effective self-management after hospital discharge
	Promoting exercise following surgery
	Providing effective support to patients with ongoing recovery problems

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Table 2:

Characteristics of patients and caregivers who participated in the surveys

Characteristic	No. (%) of respondents
Characteristic	Patients n = 31	Caregivers n = 5
Age, yr
≤ 50	1 (3)	1 (20)
51–60	1 (3)
61–70	14 (45)	3 (60)
71–80	12 (39)	1 (20)
> 81	3 (10)
Sex
Female	19 (61)	3 (60)
Male	12 (39)	2 (40)
Currently working
Yes	10 (32)	3 (60)
No	21 (68)	2 (40)
Education
Did not complete high school	10 (32)
High school diploma	9 (29)	1 (20)
College or technical school diploma or degree	3 (10)	3 (60)
Undergraduate university degree
Graduate university degree	6 (19)	1 (20)
Other (no formal education)	3 (10)

Note: This table describes the patients and caregivers who responded to the first round of the survey. Of this group, 27 patients and 5 caregivers responded to the second round survey.

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Table 3:

Characteristics of clinicians who participated in the surveys

Characteristic	No. (%) of respondents n = 27
Sex
Female	13 (48)
Male	14 (52)
Type of practice
Orthopedic surgery	7 (26)
Physiotherapy	8 (30)
Occupational therapy	3 (11)
Family medicine/general practice	8 (30)
Orthopedic nursing	1 (4)
South Asian ethnicity
No	15 (56)
Yes	12 (44)
Length of time providing care to South Asian patients who undergo TKA, yr
< 5	7 (26)
6–10	3 (11)
> 10	17 (63)

Note: This table describes the clinician who responded to the first round of the survey. Of this group, 25 responded to the second round survey.

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Table 4:

Delphi responses for “strong support” (“essential” or “very important”), by survey round and stakeholder group

Research topic	No. (%) of respondents; survey round, stakeholder group

	First round			Second round

	Patients and caregivers n = 36	Clinicians n = 27	Combined n = 63	Patients and caregivers n = 32	Clinicians n = 25	Combined n = 57
Information on lifestyle changes to prevent or delay osteoarthritis	25 (70)	22 (81)	47 (75)	27 (84)	23 (92)	50 (88)

Improving other surgical techniques to avoid or delay need for knee replacement surgery	28 (78)	7 (26)	35 (56)	26 (81)	7 (28)	33 (58)

Managing knee symptoms to avoid or delay need for knee replacement surgery	24 (67)	18 (67)	42 (67)

Understanding differences between patient and surgeon views on the right time for knee replacement	30 (83)	18 (67)	48 (76)	29 (91)	17 (68)	46 (81)

Improving wait times for surgery	27 (75)	19 (70)	46 (73)	29 (91)	18 (72)	47 (82)

Effectively managing knee pain before surgery	26 (72)	18 (67)	44 (70)	27 (84)	21 (84)	48 (84)

Information on lifestyle changes before surgery to improve recovery after surgery	25 (69)	23 (85)	48 (76)	28 (88)	24 (96)	52 (91)

Improving patient understanding of what to expect during and after surgery	31 (86)	22 (81)	53 (84)	30 (94)	21 (84)	51 (90)

Providing emotional and psychological support to patients before surgery from other patients	20 (56)	11 (41)	31 (49)

Providing emotional and psychological support to patients before surgery from professional counsellors	18 (50)	8 (30)	26 (41)

Improving knee implants that allow for kneeling, squatting and walking downhill	31 (86)	17 (63)	48 (76)	29 (91)	16 (64)	45 (79)

Improving surgical practices for best healing and scar minimization	25 (70)	11 (41)	36 (57)

Understanding the role of genetics in surgical scar formations	20 (56)	5 (18)	25 (40)

Managing other illnesses while in hospital including medication interaction	25 (70)	15 (56)	40 (64)

Promoting respectful behaviour between patients and clinicians in clinical settings	21 (58)	15 (56)	36 (57)

Improving practices for physiotherapy after surgery	32 (89)	23 (85)	55 (87)	30 (94)	23 (92)	53 (93)

Understanding differences between the patient and clinician views on the right time to discharge from the hospital	24 (67)	17 (63)	41 (65)

Effectiveness of discharge to a rehabilitation hospital before being sent home	25 (70)	11 (41)	36 (57)

Integrating family doctors into surgery recovery at the hospital and after discharge from hospital	23 (64)	13 (48.1)	36 (57)

Exploring the best role of the surgeon after hospital discharge	33 (92)	9 (33)	42 (67)	28 (88)	9 (36)	37 (65)

Effective use of pain medication after hospital discharge	29 (81)	22 (81)	51 (81)	28 (88)	20 (80)	48 (84)

Effective support from the health care system after surgery	32 (89)	19 (70)	51 (81)	28 (88)	19 (74)	47 (82)

Effective self-management after hospital discharge	31 (86)	23 (85)	54 (86)	29 (91)	23 (92)	52 (91)

Promoting exercise following surgery	33 (92)	23 (85)	56 (89)	30 (94)	24 (96)	54 (95)

Providing effective support to patients with ongoing recovery problems	27 (75)	16 (59)	43 (68)	29 (91)	15 (60)	44 (77)

Note: In the first round of the survey, 61% of eligible patients and caregivers and 82% of eligible clinicians participated; the combined response rate was 69%; 89% of the patients and caregivers and 93% of the clinicians who participated in the first round also participated in the second round. The combined response rate was 90% in the second round.