A patient satisfaction survey investigating pre- and post-operative information provision in lower limb surgery

Planned lower-limb operations, such as knee and hip replacement, can be very effective treatments which are becoming increasingly commonly used [1‐3]. These procedures are primarily used for Osteoarthritis (OA), a common degenerative condition of the joints, which is increasing in prevalence due to ageing populations and the obesity epidemic [4]. Over 92,000 hip and 98,000 knee arthroplasty operations were performed across the UK in 2018, an increase of 53 and 37% respectively since 2007 [5]. These numbers have been predicted to quadruple by 2035 [6]. However, patient dissatisfaction after knee arthroplasty is high, estimated to range between 8 and 17% [7].

Non-joint replacement operations are also common in the lower limb. It is estimated that over 15,000 Anterior Cruciate Ligament Reconstruction (ACLR) operations are performed in the UK each year [8]. Additionally, approximately 40,000 meniscal injuries requiring meniscectomy occur in the UK per year [9]. Traditionally, these injuries have been caused by traumatic sporting events and have been associated with future onset of OA, further increasing the burden of joint replacement services [10, 11]. These procedures have also been impacted by overly optimistic expectations, which may lead to long-term dissatisfaction with their outcomes [12].

Previous studies have measured satisfaction as well as functional outcomes or Patient Reported Outcomes (PROs) in lower limb surgery, concluding that three elements are key in maintaining high levels of satisfaction. These include meeting preoperative expectations, adequate pain relief and the patient’s subjective hospital experience [13, 14]. The strongest predictor of dissatisfaction after total knee replacements or ACLR procedures is the failure to meet patients’ preoperative expectations [12]. This demonstrates a lack of information being passed on the patient or a lack of understanding of the information being given. Thus, preparing patients more effectively before surgery may provide better satisfaction and functional outcomes [15].

Measuring outcomes has become an increasingly important tool in the field of medicine, however satisfaction largely remains an undefined and difficult to measure parameter, especially regarding information provision within a clinical setting [16]. Whilst PROs are established healthcare quality measurements, patients are sometimes disappointed that questionnaires often do not ask them the right questions [17]. Even though evaluators use satisfaction as a single measure to reflect quality, satisfaction is multifactorial and requires capturing patient views more comprehensively than merely through simple scales, which are frequently used in surveys [18]. To fully capture the patient experience, open ended questions and more detailed assessments are needed to enable patients to offer a holistic view on the information and care they received [16]. This project’s uniqueness stems from directly asking patients which resources they would prefer and in which format these would be best received, an aspect that the aforementioned studies have neglected.

It has been suggested that by ensuring adequate patient education and realistic goal setting, patient satisfaction could be improved [19, 20]. Additionally, with the WHO’s global strategy on people-centred care and integrated health models becoming more prevalent, a simple yet effective method of ensuring the patient is at the heart of clinical decisions must be identified and utilised. Healthcare professionals must provide relevant, effective and tailor-made information in the medium best suited to or requested by the patient, to ensure they are able to make the most informed decision possible [21]. To achieve both these targets, we must first ascertain if patients are satisfied with the information they receive, pertaining their operations.

This project is set in a National Healthcare Service (NHS) run tertiary orthopaedic centre in the West Midlands that provides free at the point of care services and is currently rated “good” by the Care Quality Commission [22]. At the moment, within the Trust assessed, patients receive a consultation with a surgeon, an appointment with a physiotherapist prior to their operation, and a leaflet relevant to their operation. However, patients have not been involved in the production of the leaflets. Patients undergoing joint replacement procedures will be invited to a group session, with other patients, to discuss exercises and extra support options with a trained nurse practitioner. Post-operatively, all patients are given further appointments with their surgeon at 6 weeks, 6 months and 1 year. They are also given six weekly sessions with a physiotherapist and a telephone number to call in case they have any issues. Currently, patients do not have any electronic resources provided by the Trust and although every effort is made to provide patients with a robust and individualised experience, cost restrictions and workforce limitations hinder the development and implementation of such resources. Electronic resources such as educational videos and an app based post-operative educational system are currently in development but have not been completed. This project may therefore help guide what should be included within these, to meet the needs of the study population. The project also aims to assess whether sub-groups of the patient population require different resources, to propose ways of achieving more effective information provision within this lower limb surgical department.

The primary aim of this project was to evaluate patients’ satisfaction with the information received during their operative experience and propose improvements. In general, patients were satisfied with the information and care they received. Some resources were found more useful than others and leaflets do not appear to meet the needs of the patient population anymore. Very few patients received or viewed webpages pertaining their procedure, but it was clear that many patients would value this. Exposing patients to other individuals who had undergone the same operation had a variable impact. Patients have reported that they want more specific and succinct information that applied to them and the procedure they are undertaking. Further information was requested on the topics of post-operative pain, recovery, the procedure and who would be in theatre with them.

In this exploratory study, patients were generally satisfied with the information and care they received but not all elements of the information were found useful. This could be improved by the production of webpages that include educational videos, patient experiences and an interactive recovery timeline or by developing expert patient blogs to aid clarity of post-operative expectations. Other proposed electronic resources include a mobile information platform that is tailored to each procedure, that can ask healthcare professionals questions or give access to FAQs that patients can refer to when the time is right. Patient involvement in the development and delivery of resources would be worthwhile and would enhance the resources developed. These suggestions may enable NHS Trusts to “get into the digital age”, however, more research on patient satisfaction around information provision and the impact it has on recovery as well as decision making is needed.