The moving target: why elderly patients don't choose joint replacement

[Guest guest]

The moving target: why elderly patients don't choose joint replacement

Jul 30, 2004 Janis

Toronto, ON - Older patients with disabling arthritis don't decide against

joint-replacement surgery so much as they just keep deferring the decision.

As patients age, they weigh perceived costs and benefits against an

ever-changing threshold at which the risks would tilt in favor of surgery,

Drs Jocalyn P , G , and colleagues at the University of

Toronto report. The researchers call this the " moving target " in an analysis

of elderly patients' decision making published in the July 2004 issue of

Journal of Bone and Joint Surgery [1].

These patients often have incomplete and often incorrect information about

the potential benefits of joint replacement, particularly with regard to

pain relief. " Even if physicians are talking to elderly arthritis patients

about the benefits of joint-replacement surgery, the message is not getting

through, " tells rheumawire.

What constitutes a " net gain " changes as patients age

says that this study was inspired in part by early work showing that

only about 10% of patients with arthritis who are candidates for total joint

replacement according to clinical criteria are definitely willing to

consider it. The goal of the study was to understand how patients who do not

want to undergo joint replacement arrive at that decision. The researchers

found that symptoms and information sources are the 2 most important factors

in decision making, that patients go through an individualized process of

trading off perceived costs and benefits, and that the threshold for a

decision in favor of surgery changes as patients age.

It was a challenge for some patients to consider undergoing total joint

replacement to improve quality of life in the context of a shrinking life

span.

" What patients are willing to adapt to increases as they age, " says.

This led to the development of a new model to describe the decision-making

process, which is based on a shifting evaluation of risks and benefits.

The researchers also found that patients' decision making included a poorly

defined end point of pain and immobility and that the " limits of the

individual's willingness to cope with the pain and dysfunction of arthritis

continued to be extended " with increasing age.

" It was a challenge for some patients to consider undergoing total joint

replacement to improve quality of life in the context of a shrinking life

span, " says. " Because accommodation to symptoms was the chief

strategy, trade-offs became detailed in terms of what was 'cope-able,' and

the limit to which the individual could cope continued to be extended. "

First study on patients who refuse joint replacement

says that most research on patients' decision making has focused on

people who come to their physicians ready to make a decision. This one

focused on patients who are resisting such a decision. The research sample

was drawn from a group of 176 individuals in Toronto who had severe

lower-extremity arthritis and were unwilling to consider total joint

replacement. All eligible had Western Ontario and McMaster Universities

(WOMAC) Osteoarthritis Index Scores of >39 on a scale of 100 and arthritis

confirmed by radiography. Of the original 176 patients, 30 had undergone

previous joint-replacement surgeries and were excluded, as were 80 with

lower WOMAC scores, 5 with psychiatric or neurological disorders, and 14

whose poor health precluded participation. This left 47 patients, 17 of whom

agreed to participate in the study.

The researchers conducted in-home interviews using a semistructured

interview guide that focused on 2 key areas. The first was the information

the patients had received about total joint replacement and the support they

could expect if they had the procedure. The second was their preferences,

motivations, and needs regarding arthritis management in general and joint

replacement in particular.

Qualitative content analysis, which involves identifying, coding, and

categorizing patterns, was used to analyze the 17 interview transcripts.

Does " no " mean " no " ?

As expected, pain was " an ongoing presence in the lives of all

participants. " This caused substantial disability, but patients often did

not consider even debilitating and severe episodes sufficient to warrant

total joint replacement.

Pain was also viewed as a natural and expected component of aging, not

something to be treated with total joint replacement. This, in part,

reflects patients' doubts that joint replacement would relieve the arthritis

pain.

This, in turn, might reflect the fact that " most of our participants claimed

not to have had good or complete information about total joint replacement

in general or about its utility in their particular case, " the investigators

write. The information gap was partly filled by (sometimes inaccurate)

information from lay sources and peers, some of which minimized expected

benefits and inflated expected risks.

" Physicians take 'I'm thinking about it' as a 'no' and don't engage in

discussions of how severe pain or disability would have to be before the

patient would opt for joint replacement, " says. He suspects that

since joint pain and disability are largely seen as quality-of-life issues

rather than conditions requiring definite care, such as hypertension,

physicians " tend to step back " and not repeatedly bring up the topic.

The investigators also uncovered significant concerns about a lack of social

support during the process of recovery. " In the absence of social support,

unwillingness to consider total joint replacement may be a reasonable

decision, " they note.

Source

1. JP, Hudak PI, Hawker GA, et al. The moving target: a

qualitative study of elderly patients' decision-making regarding total joint

replacement surgery. J Bone Joint Surg Am 2004; 86:1366-1374.

[Guest guest]

Interesting article. One thing that seems to be lacking is what

joints are under consideration for replacement. There is a good

chance things will work out for the better if you are talking about a

hip or knee replacement, those seem to work well. But not if you are

talking about ankles or wrists. There seems to be a long way to go

to make those joint replacements viable options.

Jennie

> The moving target: why elderly patients don't choose joint

replacement

>

> Jul 30, 2004 Janis

>

> Toronto, ON - Older patients with disabling arthritis don't decide

against

> joint-replacement surgery so much as they just keep deferring the

decision.

> As patients age, they weigh perceived costs and benefits against an

> ever-changing threshold at which the risks would tilt in favor of

surgery,

> Drs Jocalyn P , G , and colleagues at the

University of

> Toronto report. The researchers call this the " moving target " in an

analysis

> of elderly patients' decision making published in the July 2004

issue of

> Journal of Bone and Joint Surgery [1].

>

> These patients often have incomplete and often incorrect

information about

> the potential benefits of joint replacement, particularly with

regard to

> pain relief. " Even if physicians are talking to elderly arthritis

patients

> about the benefits of joint-replacement surgery, the message is not

getting

> through, " tells rheumawire.

> What constitutes a " net gain " changes as patients age

>

> says that this study was inspired in part by early work

showing that

> only about 10% of patients with arthritis who are candidates for

total joint

> replacement according to clinical criteria are definitely willing to

> consider it. The goal of the study was to understand how patients

who do not

> want to undergo joint replacement arrive at that decision. The

researchers

> found that symptoms and information sources are the 2 most

important factors

> in decision making, that patients go through an individualized

process of

> trading off perceived costs and benefits, and that the threshold

for a

> decision in favor of surgery changes as patients age.

>

>

> It was a challenge for some patients to consider undergoing

total joint

> replacement to improve quality of life in the context of a

shrinking life

> span.

>

>

>

> " What patients are willing to adapt to increases as they age, "

says.

> This led to the development of a new model to describe the decision-

making

> process, which is based on a shifting evaluation of risks and

benefits.

>

> The researchers also found that patients' decision making included

a poorly

> defined end point of pain and immobility and that the " limits of the

> individual's willingness to cope with the pain and dysfunction of

arthritis

> continued to be extended " with increasing age.

>

> " It was a challenge for some patients to consider undergoing total

joint

> replacement to improve quality of life in the context of a

shrinking life

> span, " says. " Because accommodation to symptoms was the chief

> strategy, trade-offs became detailed in terms of what was 'cope-

able,' and

> the limit to which the individual could cope continued to be

extended. "

> First study on patients who refuse joint replacement

>

> says that most research on patients' decision making has

focused on

> people who come to their physicians ready to make a decision. This

one

> focused on patients who are resisting such a decision. The research

sample

> was drawn from a group of 176 individuals in Toronto who had severe

> lower-extremity arthritis and were unwilling to consider total joint

> replacement. All eligible had Western Ontario and McMaster

Universities

> (WOMAC) Osteoarthritis Index Scores of >39 on a scale of 100 and

arthritis

> confirmed by radiography. Of the original 176 patients, 30 had

undergone

> previous joint-replacement surgeries and were excluded, as were 80

with

> lower WOMAC scores, 5 with psychiatric or neurological disorders,

and 14

> whose poor health precluded participation. This left 47 patients,

17 of whom

> agreed to participate in the study.

>

> The researchers conducted in-home interviews using a semistructured

> interview guide that focused on 2 key areas. The first was the

information

> the patients had received about total joint replacement and the

support they

> could expect if they had the procedure. The second was their

preferences,

> motivations, and needs regarding arthritis management in general

and joint

> replacement in particular.

>

> Qualitative content analysis, which involves identifying, coding,

and

> categorizing patterns, was used to analyze the 17 interview

transcripts.

> Does " no " mean " no " ?

>

> As expected, pain was " an ongoing presence in the lives of all

> participants. " This caused substantial disability, but patients

often did

> not consider even debilitating and severe episodes sufficient to

warrant

> total joint replacement.

>

> Pain was also viewed as a natural and expected component of aging,

not

> something to be treated with total joint replacement. This, in part,

> reflects patients' doubts that joint replacement would relieve the

arthritis

> pain.

>

> This, in turn, might reflect the fact that " most of our

participants claimed

> not to have had good or complete information about total joint

replacement

> in general or about its utility in their particular case, " the

investigators

> write. The information gap was partly filled by (sometimes

inaccurate)

> information from lay sources and peers, some of which minimized

expected

> benefits and inflated expected risks.

>

> " Physicians take 'I'm thinking about it' as a 'no' and don't engage

in

> discussions of how severe pain or disability would have to be

before the

> patient would opt for joint replacement, " says. He suspects

that

> since joint pain and disability are largely seen as quality-of-life

issues

> rather than conditions requiring definite care, such as

hypertension,

> physicians " tend to step back " and not repeatedly bring up the

topic.

>

> The investigators also uncovered significant concerns about a lack

of social

> support during the process of recovery. " In the absence of social

support,

> unwillingness to consider total joint replacement may be a

reasonable

> decision, " they note.

>

> Source

>

> 1. JP, Hudak PI, Hawker GA, et al. The moving target: a

> qualitative study of elderly patients' decision-making regarding

total joint

> replacement surgery. J Bone Joint Surg Am 2004; 86:1366-1374.