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Patient and health professional views on rehabilitation practices and outcomes following total hip and… Westby, Marie D; Backman, Catherine L May 11, 2010

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Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Open AccessR E S E A R C H  A R T I C L EResearch articlePatient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group studyMarie D Westby*1,2 and Catherine L Backman1,3,4AbstractBackground: There is worldwide variation in rehabilitation practices after total hip arthroplasty (THA) and total knee arthroplasty (TKA) and no agreement on which interventions will lead to optimal short and long term patient outcomes. As a first step in the development of clinical practice guidelines for post-acute rehabilitation after THA and TKA, we explored experiences and attitudes about rehabilitation practices and outcomes in groups of individuals identified as key stakeholders.Methods: Separate focus groups and interviews were conducted with patients (THA or TKA within past year) and three health professional groups: allied health professionals (AHPs), orthopaedic surgeons, and other physicians, in Canada and the United States. Pairs of moderators led the focus groups using a standardized discussion guide. Discussions were audiotaped and transcribed verbatim. A content analysis within and across groups identified key themes.Results: Eleven focus groups and eight interviews took place in six sites. Patients (n = 32) varied in age, stage of recovery, and surgical and rehabilitation experiences. Health professionals (n = 44) represented a range of disciplines, practice settings and years of experience. Six key themes emerged: 1) Let's talk (issues related to patient-health professional and inter-professional communication); 2) Expecting the unexpected (observations about unanticipated recovery experiences); 3) It's attitude that counts (the importance of the patient's positive attitude and participation in recovery); 4) It takes all kinds of support (along the continuum of care); 5) Barriers to recovery (at patient, provider and system levels), and 6) Back to normal (reflecting diversity of expected outcomes). Patients offered different, but overlapping views compared to health professionals regarding rehabilitation practices and outcomes following THA and TKA.Conclusion: Results will inform subsequent phases of guideline development and ensure stakeholders' perspectives shape the priorities, content and scope of the guidelines.BackgroundTotal hip arthroplasty (THA) and total knee arthroplasty(TKA) surgeries are highly successful orthopaedic proce-dures for more than 62,000 Canadians [1] and 773,000Americans [2] each year. The growth in number of THAsand TKAs exceeds the aging of our population due inpart to both younger and older individuals electing jointreplacement surgery as a feasible option for theiradvanced hip and knee osteoarthritis (OA) [3].Nearly all patients receive post-operative physical ther-apy and/or other rehabilitative services in the hospital, asan outpatient or through home care services [4]. How-ever, the setting, timing, amount and treatmentapproaches differ widely [5-8]. Despite the cost effective-ness of THA and TKA, in-hospital and rehabilitationcosts associated with these surgeries place significantburdens on North American healthcare systems [2,9-11].* Correspondence: marie.westby@vch.ca1© 2010 Westby and Backman; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and repro-duction in any medium, provided the original work is properly cited.Rehabilitation interventions (e.g., physical therapy, occu- Rehabilitation Sciences Research Graduate Program, Faculty of Medicine, University of British Columbia, Vancouver, CanadaFull list of author information is available at the end of the articleWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 2 of 15pational therapy, nursing care) may enhance surgical out-comes; however, their precise contribution to long-termoutcomes such as physical function, mobility, participa-tion in life roles and health-related quality of life(HRQoL) is not clear. A National Institutes of Health(NIH) conference concluded that "...rehabilitation ser-vices are perhaps the most understudied aspect of theperi-operative management of TKA patients" [12].Disparate views on need for total joint arthroplasty(TJA) surgery, expectations and outcomes of surgery havebeen reported for physicians and patients [13-15], andbetween surgeons and other health professionals [16].Hewlett suggests that patients' assessments may differfrom those of health professionals due to the influence ofneeds, attitudes, priorities, experiences and expectations[17]. It is therefore necessary to explore patient and pro-vider expectations to inform clinical practice guidelines.The Canadian health care system is characterized byuniversal access and government funded health care forphysician and hospital-based services, few for-profit pro-viders, and lower national health care expenditures thanin the US [18], with its varied access to public and privateproviders depending on one's insurance. These differ-ences in turn influence surgical wait times [1], access toand funding for rehabilitation services, and health out-comes [18]; thus the need to incorporate both perspec-tives.The purpose of this study was to move beyond theexisting literature and explore patient and health profes-sional experiences with current rehabilitation practicesand outcomes following THA and TKA to inform thedevelopment of clinical practice guidelines applicable forNorth America.MethodsSampling frameWe were interested in perspectives from four stakeholdergroups: 1) individuals who had a primary THA or TKAfor OA within the past year; 2) allied health professionals(AHPs, e.g., physical therapist (PT), occupational thera-pist (OT), nurse, medical social worker) currently provid-ing THA or TKA rehabilitative care, education orcounseling; 3) physicians (e.g., rheumatologist, physia-trist, family practitioner) who provide THA or TKA care;or 4) orthopaedic surgeons currently performing THA orTKA. Patients were excluded if they were less than 19years of age, could not converse in English; or had under-gone THA or TKA surgery for inflammatory arthritis,acute fracture/trauma or tumour. Spouses were permit-ted to join the patient discussion groups.experience. Notices, inviting interested individuals tocontact the local study coordinator, were posted in clin-ics, waiting rooms, seniors' centers and arthritis con-sumer groups' newsletters as applicable to eachstakeholder group. E-mail notices were distributed usingstaff directories for all types of health professionals.Focus Groups/InterviewsFocus groups are particularly suited to studying diverseperspectives to gain insight into participants' experiences[19,20] and were the primary means of gathering data,where possible. Focus groups encourage contributionsfrom less verbal individuals who feel supported by othergroup members with shared experiences [21]. However,individual interviews were conducted when participantswere unable to attend their group. Both focus groups andinterviews have been used previously in studying variousaspects of THA and TKA care, patient experiences andexpectations [22-27], but we are not aware of studies thatexamine THA and TKA rehabilitation practices and out-comes from multiple stakeholders' perspectives.A discussion guide was developed with input from amulti-disciplinary group of clinicians experienced inTHA and TKA rehabilitation and researchers experi-enced in focus group methodology. Open-ended ques-tions progressed from general and uncued to morespecific questions with accompanying probes [20,28].The discussion guide was tested twice and revised toimprove clarity based on health professional and patientfeedback. Key questions and probes [Appendix A] wererephrased for each stakeholder group to ensure relevanceto participants [20]. Separate focus groups were con-ducted with each set of stakeholders to avoid a perceivedhierarchy among mixed professional and professional-patient participants [29].A pair of moderators led each focus group using thestandardized discussion guide. The four moderators werefemale PTs with experience in TJA rehabilitation andgroup process and included the lead author. Prior to thefirst focus group, moderators were given written and vid-eotaped instructions on focus group methodology, mod-erating tips and use of the data collection forms, and eachpair conducted a pilot session to gain skill and confidencein moderating sessions and trouble shoot problemsrelated to audiotaping, timing and logistics.Focus group sessions lasted 90 minutes for health pro-fessionals and 120 minutes for patient groups (allowingfor a stretch break). Individual semi-structured inter-views (face-to-face or telephone) of 30-60 minutes wereconducted with participants unable to participate in afocus group; they followed the discussion guide. SessionsRecruitmentWe therefore used strategies to accrue a purposive sam-ple across stakeholder group, demographics and level ofwere audiotaped and transcribed verbatim for analysis.Participants recorded thoughts on a response form priorto sharing their perspectives with other group members.Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 3 of 15Forms were collected and together with the moderators'field notes served to enrich transcripts and study rigor[30]. Member checking was incorporated into focusgroups and interviews by inviting participant feedback onthe moderator's summary of the session [21]. Immedi-ately following each focus group, the moderators met todebrief, identify issues that may influence analysis andsuggest possible modifications to the discussion guide[21].Ethical approval was received from the UBC BehavioralResearch Ethics Board and the Vancouver Coastal HealthResearch Institute for the primary site and as required byinstitutional policy for each of the other sites. All partici-pants provided informed consent prior to participation,and were offered a small token ($10 gift certificate).Data analysisA thematic content analysis occured concurrently withdata collection to allow for revision of questions anddevelopment of new lines of inquiry [20,21,29,31]. Afterchecking transcripts for accuracy, the two authors inde-pendently read the transcripts and performed line-by-line, open coding [29], and, following the process out-lined in Figure 1, developed sub-themes for 'within groupanalysis' and subsequently refined these into key themesfor 'across group analysis'. Disagreements in coding andcategorization were discussed and the coding frameworkrefined as necessary using a constant comparisonapproach [29]. Minority opinions or outliers (negativecases) were identified and discussed [30].Data collection was discontinued when it was agreedthat no new ideas or issues were likely to be raised[20,29]. A decision audit trail was maintained throughoutthe data collection and analysis phases. Once key themeswere identified, transcripts were reviewed and represen-tative quotes selected for each theme. Portions of thecoding framework and final analysis were shared with anindependent, experienced qualitative researcher for peerchecking [30].ResultsEleven focus groups and eight semi-structured interviewswere conducted in five Canadian and one US site. Partici-pants included 32 patients and four spouses, 30 AHPs,five physicians and nine surgeons [Tables 1 &2]. Despiteefforts to recruit an ethnically diverse sample, patientswere primarily Caucasian but included one AfricanAmerican and one Aboriginal person living on reserve.Allied health professional groups included PTs, OTs,nurses, physician assistants, social workers, and a rehabil-itation assistant and fitness professional. Physiciansincluded family practitioners, physiatrists and a rheuma-tologist. Focus groups ranged in size from four to 10 par-ticipants.Key ThemesWithin group analyses for each stakeholder groupresulted in the subthemes summarized in Tables 3, 4, 5and 6. Further comparison using constant comparisonacross groups uncovered six major themes. Thus, sub-theme labels reflect concepts specific to each groupwhereas the key themes reflect concepts across all partic-ipants. Quotes are attributed to participants by notingtheir age, gender and group, e.g., 41, F, FP is a 41 year old,female, family practitioner.Theme 1: Let's talkA substantial amount of focus group time was spent dis-cussing communication issues. The greatest energy andstrongest group interaction occurred over the issues ofinter-professional communication and collaborationacross settings and throughout the continuum of care.While participants offered descriptions of both positiveand negative patient-provider and inter-provider com-munication, most examples described how poor or lackof communication decreased efficiency, effectiveness andcollaboration."Communication amongst all the people involved ispretty much non-existent. There's no communicationbetween surgeons and family doctors anymore." [41 F,FP]PROCESS TO ENSURE STUDY RIGOURSTEPSVerbatim transcription Independent, open line-by-line coding Clustering of common codes (by consensus) Formation & labeling of categories Formation of concepts/subthemes (within group)Identification of major Audit Trail Data Source Triangulation with moderators’ notes & participants’ response forms Primary Author’s Reflective JournalMember Checking  with study participants Peer Checkingwith independent qualitative researcher"So we have this parade of people with total hips, forexample, coming through as though they're all thesame and they're not. And I think there's a real needFigure 1 Data analysis flow chart.themes (across groups) Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 4 of 15Table 1: Patient participant demographics (n = 32)*Patients (Type of surgery)Age (Range, years) Gender (/) English as first languageEducation (Some college or higher)Post-op stage (Range, months)Rehab status (Completed rehab)Work status (Retired)Lives in urban communityTHA n = 13 46 - 81 7/6 13 10 1 - 11 7 8 9TKA n = 19 46 - 78 11/8 18 15 1 - 10 9 10 14* - patient participants only (does not include the 4 spouses)Table 2: Health professional participant demographics (n = 44)Professions Age(Range, years) Gender (/) English as first languageTJA experience1(Range, years) TJA patient volume2(Cases/year)Practice setting3 Urban-based practiceAHPsn = 3028 - 62 26/4 25 1 - 35 <50/yr = 750-100/yr = 8>100/yr = 15Inpt acute = 4Inpt rehab = 4Outpatients = 15Home care = 5Other = 222Surgeonsn = 933 - 64 0/9 7 1 - 30 50-100/yr = 1>100/yr = 8Teaching hospital = 8Regional hospital = 19Physiciansn = 541 - 60 1/4 4 6 - 35 <50/yr = 150-100/yr = 2>100/yr = 2Inpt acute = 1Inpt rehab = 1Private practice = 35AHPs = allied health professionals; TJA = total joint arthroplasty; Inpt = inpatient1 - Years of experience providing surgical, treatment or counseling services to patients with THA or TKA2 - Number of combined THA and TKA patients treated or operated on each year3 - Number of professionals practicing in each setting; for AHPs "Other" = recreational settingWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 5 of 15for us all to get better information from the surgeonand I've crowed about this for a long time and it hasn'tyet happened, but I think that's a major weakness.... Ithink this lack of information leads to rote [physicaltherapy] procedures that don't have very much think-ing going on with them." [62 M, PT]Poor communication across settings (e.g., from in-patient rehab to family practitioner or private PT) wasbelieved to contribute to inconsistent and poorly coordi-nated services and negatively impact clinical outcomesand patient satisfaction. Centralized information, a com-munication form that stays with the patient, better linksbetween facilities and providers, and practice guidelineswere suggestions shared by AHPs and physicians as waysto address this issue. 'Team care' was another approach toenhance communication and was acknowledged as morefeasible in inpatient rehabilitation settings where differ-ent healthcare providers were housed under the sameroof, shared charting and participated in regular teammeetings. Inadequate staffing, part time positions andstaff turnover negatively impacted team dynamics andconsistencies in care. A lack of a collaborative, multidisci-plinary approach was felt to lead to inefficiencies, dupli-cation of services and patient dissatisfaction."The problem in our health care system is that thebureaucratic aspect of things precludes us from beingefficient..." [36 M, SURG]Patients suggested that surgeons could improve theircommunication and understanding of what is importantto patients by:"Giving more time and listening to the patient. Assess-ing what they're saying, what the patient is saying. Togive the patient time so that they feel comfortableenough to really express themselves." [73 F, TKA]A good patient-provider relationship and open commu-nication were believed to motivate the patient and facili-tate recovery. Suggestions for opening channels ofcommunication included providing patients with contactphone numbers, calling them when they had missedappointments and liaising with the next health care pro-vider in the rehabilitation continuum to ensure timelyand efficient transfers of care."One of the things I feel is really important is thatphysiotherapy departments and physicians don't forgettheir patients. ...call and see what's going on. Manypeople seem to feel like they were forgotten and thatafter physio and they were out on their own, nobodycared." [73 M, TKA]Theme 2: Expecting the unexpectedPatients identified a number of unexpected challenges inbances, psychological issues and unrealistic activityexpectations."Nobody said how much pain and swelling there wasgoing to be." [76 F, TKA]"I think a lot of surgeons forget you've got to sleep -honest to God, they should have to go through it. Thefirst thing is you'd be offered, you know, adequate painmedication post-operative and then that sleep is thebiggest factor that you're faced with." [73 M, TKA andretired health professional]"I don't know how many people [with TKA] I've had inthe last little while that come in and they're stunnedthat they have pain postoperatively...They're so notprepared for the amount of pain they have." [43 F, PT]"...after surgery I felt like the bull AND the china shop.Like I feel I am potentially the source of my demise andI feel fragile." [57 F, THA]Of equal concern to many patients and health profes-sionals were the issues of who to go to when post-opera-tive pain was not well-managed and inconsistent adviceon whether additional analgesics (e.g. narcotics) wereappropriate after the initial acute care period."I don't think anybody tells the patients, so they gohome, they'll be getting some T3's or something by theirsurgeon or surgical RN and sometimes that's enough,but usually it's not enough... and they just don't thinkto call or they don't know who to call." [41 F, FP]"...the knowledge of pain management from thepatient's perspective and their primary care provider'sperspective is very poor." [55 M, SURG]All study participants viewed the pre-operative educa-tion and preparatory phase as being critical for clarifyingexpectations and empowering the patient."What I've noticed is the [acute care] discharges tendto go better if patients are clear on the expectations,you know, that they're informed of the possible date ofdischarge so psychologically they can start to preparethemselves. Involving social work early on to assistwith addressing the barriers or obstacles I find goeswell [42 F, SW]Unclear or unrealistic patient expectations were felt tolead to greater post-operative pain, significant anxietyand depression, and disappointment around the rate ofrecovery."I think my expectations on the recovery period wereoverly optimistic." [57 M, TKA]"They should be realistic in what they project for you."[69 M, THA]Differing expectations and views between surgeons andrehabilitation providers on patients' functional status,ongoing need for supervised physical therapy and achiev-the post-operative period for which they felt inadequatelyprepared: pain intensity and management, sleep distur-able outcomes lead to inconsistent advice, patient confu-sion, premature discontinuation of therapy and less thanoptimal outcomes. A PT described a common scenarioWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 6 of 15Table 3: Patient subthemes and sample quotes*Subtheme 1: I wasn't expecting that."I didn't realize the enormity of the procedure or the aftermath, I really didn't. So it was kind of hard on me because I didn't realize the pain I was going to have." [78 F, THA]"I asked everybody in physio. They slept an hour approximately a night for about 5 weeks. That was all. Like when you're in hospital you were doped up. As soon as you went home it was about an hour, and not just at a time. It was an hour in 24..." [46 F, TKA]"Has anybody else had a little bit of depression after the surgery? Am I the only one? I would cry over anything." [76 F, TKA]"It's exhausting for the spouse when this is going on. We've had a lot of tears and stress." [spouse of 65, M, TKA]Subtheme 2: It takes all kinds of support"Physics that explain and explain are so invaluable because we're all going through such anxiety." [64 F, TKA]"My primary care doctor was a great support. The surgeon was motivating, believes in you..." [61 F, TKA]"...if I had this to go through again I would have somebody at home, because I certainly could have used a little help at home." [76 F, THA]"...the other patients. I mean I'm basically modeling myself on all their efforts too. I think it served to sort of propel me to become more motivated." [52 M, TKA]Subtheme 3: My body, my responsibility"I think you really have to have a kind of a very positive attitude. It's not easy. It's not easy when you have a lot of pain." [75 M, TKA]"You really have to advocate strongly for yourself and the services. It's not something that is openly offered. It's a matter that you have to pursue [52 M, TKA]"If the surgeon does his part, I should do mine. I did exercises 8 to 9 months before surgery so felt confident going for surgery. I quit smoking and walked regularly [57 F, TKA]Subtheme 4: Back to normal"...to not be able to do that job anymore would be the saddest thing in my life." [46 F, THA]"The biggest thing for me is getting my walking ability back to where it was say five years ago." [73 M, TKA]"Getting up and running, jogging, whatever, riding a bike. I didn't really talk to [my surgeon] about it. I really wanted to discuss playing ice hockey but that is totally out of the question, and that was my goal..." 51 M, TKA]"Being so happy that your personality has returned. Because I'm sure that we've all had varying degrees of changes over the years just in learning how to live and manage the pain. You can walk around with a smile on your face and probably all of us feel 10 to 20 years younger." [46 F, THA]whereby the surgeon's assessment differed from that ofthe treating therapist." [The surgeon tells the patient at the 6-8 week follow-up visit] 'Oh, you're doing great. You don't need to doanymore (physical therapy).' Well, they're not doinggreat. I don't think they're gotten the best bang for theirbuck as far as the surgery, and ... you'd like to see themprogress a lot further than they are..." [43 F, PT]Health professionals voiced concerns about misinfor-mation available through the popular press and commer-cial Internet sites and said this was a growing problemleading to unrealistic expectations and a negative impacton patient recovery."Patients learn just enough to be dangerous [from theInternet]." [39 M, PT]Theme 3: It's attitude that countsHealth providers and patients alike stressed the impor-tance of the patient's attitude when it came to being anactive participant in the rehabilitation process andremaining motivated during the typical ups and downs ofrecovering from TJA surgery. Physicians and AHPs felt akey part of their roles was to help the patient in thisregard: "I like to empower the patient first and foremost."[47 M, PHYS]Patients were considered an integral part of the teamand their active participation in the rehabilitation processvital to good outcomes and greater satisfaction."I tell them 'This is what you need to do at home' andthey go home and don't practice, definitely that makesa huge difference when you see the patient next time.People are afraid to move or people are really reluc-tant to do it, so I think patient compliance with homeexercises is very effective, it's huge." [42 M, PT]"I would think that a person should be checked to makesure that they are continuing to exercise, they are usingthe leg. I think it's such a waste of money and time ifyou don't become better." [61 F, TKA]Having a positive attitude and taking a proactiveapproach to the surgery and subsequent rehabilitationphase while acknowledging the mind-body connectionwere strategies used by many patient participants."I learned to recognize that my body was wiser and farcleverer than I was so I had better just obey it." [77 M,THA]"You have to be willing to give not just 100 percent but150 percent to your own recovery." [46 F, THA]Theme 4: It takes all kinds of supportParticipants reported how different 'facets' of supportcontributed to health outcomes and overall satisfaction* Findings based on 5 focus groups and 2 interviews. Legend: Panelists are identified by age, gender (M = male, F = female) and type of surgery (THA or TKA)with the surgery and rehabilitation process. Patients andAHPs were more likely than physicians to describe peerWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 7 of 15and spousal/family support as having favorable effects onan individual's rehabilitation process."Hearing from another patient first hand and how theyexperienced it really helps the fear part of it." [43 F,RN]"The support from my spouse and my family immedi-ately after surgery was the most invaluable and won-derful. Because we are sent out of the hospital fasternow and you've just got to have that help at home." [64F, TKA]The important role of family was acknowledged indescriptions of one health care facility where a familymember was given the designation of 'coach' and encour-aged to participate in all aspects of the patient's rehabili-tation. Involving a family member was also ideal in caseswhere cultural differences and language barriers impededrehabilitation instruction. When spousal and/or familysupport was lacking, there was greater need for homesupport services. In several communities, a lack of suchservices coupled with few transitional care units/bedswas felt to contribute to longer acute hospital stays and agroup of patients "who fall into the cracks".Patients wanted to be recognized as a whole person andvalued a holistic approach, which was sometimes lacking.Patients shared stories of how feeling supportedenhanced their recovery and coping."After the [physical therapy] program she phoned meand asked me how I was doing, so that was pretty"...phases I and II in the hospital where we have our rehab and then they go into the maintenance phase, which usually is within the community. Maybe we need to work together more as a whole, from surgery on and having those different phases available to the clients." [28 F, KIN]Subtheme 6: Being able to do whatever you want to do"Decreased pain, because I think that's the thing that people most want to get rid of. Whether that's with activity or just in standing, it isn't really relevant as long as whatever they're doing is pain free." [40 F, PT]"It would be really nice if they came through the whole process without looking upon it as an enormous nightmare, that things have gone smoothly. You can't always predict everything I realize, but that they had a sense of confidence and a sense of control in the whole thing so that it's been a worthwhile process." [44 F, OT]*Findings based on 4 focus groups and 1 interview. Legend: Panelists are identified by age, gender (M = male, F = female) & profession (PT = physical therapist, OT = occupational therapist, RN = nurse, SW = social worker, PA = physician assistant, KIN = kinesiologist)Table 4: AHP subthemes and sample quotes* (Continued)Table 4: AHP subthemes and sample quotes*Subtheme 1: We all need to be on the same page"It's so hard to get information about the type of surgery... it's like pulling teeth. So lack of information is problematic and it's one of the frustrations I think most therapists face." [41 F, PT]"...because we're small, we can call up one person... so it's easy. I think it works well, the link from the communication we have, acute hospital stay to community back into the outpatient department." [44 F, OT]Subtheme 2: We each have a role to play"The patients themselves - just their attitude, their motivation. We see people for pre-op and I think 'Oh, it's going to be terrible when they have their surgery and they come back.' Right away I can tell this person's going to have a hard time." [39 M, PT]"...there's a contract between the patient and myself. They've actually given something up and I have taken it from them, so there's a bit of an obligation there as a professional to make sure I give back to them the value for what they're paying for." [61 M, PT]Subtheme 3: Patients need lots of support"...people motivate each other. They can compare notes, etcetera, but sometimes the comparison can work negatively in that they'll say 'Oh well, I had a hip surgery by Dr. whoever and I'm at this week and I'm no where near where you are'." [41 F, PT]"...it's really inconsistent among physicians in terms of who gets referred to home care and who gets referred to outpatient. There's no consistency... especially between health regions." [31 F, OT]Subtheme 4: Barriers to patients reaching their full potential"...some patients run out of physical therapy appointments. You know, their insurance only pays for 12 a year or something, and so you hit the 12 mark and there's not a whole lot you can do except for rely on them to do the exercises at home, and it can be a major impediment." [30 F, PA]"...the [public] system the way that it's designed doesn't really follow through long enough. I'd like to have a six-month follow-up with these patients because I believe that most of the improvement that they see will occur in that early time. There are some gaps and I believe people sometimes don't reach their potential because of those gaps." [61 M, PT]Subtheme 5: Rehabilitation is a continuum"We get a lot of feedback from patients that tell us that getting to see the physical therapist [pre-op] and sort of train for the experience as though it's a sporting event and they have to be in shape for it... so that they're in shape to cope good. It gives a little bit of feedback to the people andwith what happens after the surgery." [53 F, RN]they feel inside that at least somebody cares aboutthem." [58 M, THA]Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 8 of 15Table 5: Surgeon subthemes and sample quotes*Subtheme 1: Communication is the key"...there's often times not enough communication between the orthopaedic surgeon and the therapist, the internist, the physical medicine doc, so that poses a particular difficulty" [36 M, SURG]"A good part of healing is communication between provider and the recipient." [56 M, SURG]Subtheme 2: Different expectations"I think that as I'm learning as I'm going through, the expectations of a patient and the expectations of the physician are often different. They may not be well communicated at all times." [33 M, SURG]"...depending on how much time you have to spend with people and so on. You may miss the boat in terms of what they're expecting." [>55 M, SURG]Subtheme 3: Professsional support"...what I do in my practice is tell patients that when I put a total joint in you, follow up is extremely important. It is the duty of the surgeon to maintain contact with his patients." [64 M, SURG]"...by three months, I can usually determine how people are going to do and either reassure them and send them off or follow up on an as needed basis only... I think it's probably a waste of time to bring people who were doing well at discharge back for a long term follow-up." [56 M, SURG]Subtheme 4: Barriers to recovery"So you play this game with the insurance company and you get caught in the middle of the game as a patient...One of the biggest changes we've seen is with rehab. You know, only a certain patient population can now go to rehab and it's not the population you'd think." [33 M, SURG]"The other thing that's non-existent for the most part is home physical therapy for the debilitated patient or the patient who is unable to get transportation somewhere or has social issues that would preclude them from being able to get to therapy. Those patients fall through the cracks, and for them it's a huge issue." [36 M, SURG]"...approaches from physiotherapists vary greatly so that I don't refer anybody to a therapist for any purpose without knowing what their approach is." [56 M, SURG]Sub-theme 5: Outcomes"Well, the main indication for joint replacements is disabling pain and stiffness, and so the most important outcome is pain relief." [56 M, SURG]"I recognize that it's a professional conflict to a certain extent but the ultimate responsibility for the outcome falls to the hands of the surgeon and if the therapist from the patients' perspective makes them worse or doesn't do a good job, it doesn't really matter because they still blame the surgeon in a sense for their poor outcome." [55 M, SURG]Physicians discussed their role in supporting and coun-seling TJA patients, however, both family practitionersand specialists expressed concerns over their ability tospend sufficient time with patients. The 'system' wasmost often blamed for not allowing for protracted con-versations with patients: "Physicians don't get paid ade-quately to provide counseling on an ongoing basis topatients." [62 M, FP] Patients also expressed their frustra-tion in accessing their surgeon post-operatively."Does anyone find it important to have access to yoursurgeon, which is almost impossible? Anything, justhearing him, you know, on the phone even. Maybe youwant to say something that's been bothering you andI'm sure you're not the only one that's ever bothered,but you feel reassured." [75 M, TKA]Another area of professional support overlapped withcommunication concerns; it was believed that health pro-fessional advice and guidance should be more consistentto be helpful:"... and I know that we can't all give the same exercisesbut I think everyone - we all have slightly differentmessages, we say slightly different things as to how longit's going to take or talking about the wound or talkingabout pain management. It would be really good if wecould have some sort of education or something that'sa little bit more consistent as far as the message that'sgoing out for people." [43 F, PT]"They're not standardized. I'm just thinking, there's allsorts of physiotherapy clinics around and they all dodifferent kinds of things...." [57 F, THA]Theme 5: Barriers to recoveryParticipants identified patient, provider and system levelfactors as being barriers to recovery after TJA. Patientfactors such as pain coping, motivation, attitude, state ofreadiness for treatment, psychological distress and self-efficacy were felt to influence the acute care hospital stay,course of recovery and participation in rehabilitation."...pain management after total knee replacement isprobably one of the biggest barriers to recovery." [55 M,SURG]"One of the most common [concurrent] diagnoses thatgets noticed is depression in the patients ... whichhugely affects motivation, adherence to the protocols,and follow up, and it doesn't get addressed frequentlybecause primary care physicians don't take the time todiagnose it appropriately. It's probably the most widelyunder diagnosed and under treated condition." [53 F,RN]Physicians and surgeons saw the role of rehabilitationafter TJA as being "to enhance the safety of the [surgical]* Findings based on 2 focus groups and 2 interviews. Legend: Panelists are identified by age, gender (M = male, F = female) and profession (SURG = surgeon)procedure and make it easier for the patient to recover."[64 M, SURG] However, the quality of rehabilitation, andin particular physical therapy services, was frequentlyWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 9 of 15thought to be poorly administered and therefore moredetrimental to patients' recovery than helpful."I have little faith in the ability of the external provid-ers to provide appropriate care for my patients and Itend to dissuade them from pursuing outpatient physi-cal and occupational therapy after surgery. ...my expe-rience has been that they [therapists] tend to do moreharm than good." [55 M, SURG]While several surgeons described having a good rela-tionship with rehabilitation professionals and expressedconfidence in their referral to post-operative physicaltherapy services, others did not: "We are sending theminto a dark, black hole." [60 M, SURG]At both patient and provider levels, language barriersand lack of translated educational materials were believedto compromise AHPs' ability to provide effective andtimely education and support in a variety of rehabilitationsettings. At the system level, issues related to access torehabilitation were common to both Canadian andAmerican participants; however, the contributing factorsdiffered in important ways. Prolonged waits for surgicalconsultation, TJA surgery and in some cases, outpatientrehabilitation were unique to Canadian experiences."...the Canadian system should be very clearly differen-tiated from the American. Their healthcare system istotally different. There's no similarity at all. ...we havethe longest waiting list in the Western world." [60 M,SURG]"...when it comes to the physio after, there don't seem tobe more physiotherapy spaces. We all experienced lon-ger waits. And we've all felt we've developed slowerbecause of this extra wait." [64 F, TKA]Caps on physical therapy and rehabilitation servicesthrough private health insurers and managed health carepractices were at issue in the American experience. Lim-ited healthcare resources, ever-changing funding formu-las and costs of rehabilitation services concerned allstakeholder groups in both countries."If [patients] don't do physio it's usually because it'sgoing to be expensive and they don't have extendedhealth [insurance]." [41 F, FP]"Medicare has put a cap on the amount of money thatyou can get in terms of the physical therapy and I thinkthat's wrong. People vary too much in how they respond tosurgery and to put a dollar value on that is totally crazy."[72 F, TKA]With limits on access to supervised rehabilitation,patients and providers had to decide how and when touse their 'allotment'. While some surgeons routinely sentpeople for physical therapy before surgery (pre-hab), oth-ers felt that rehabilitation postoperatively was of greaterTable 6: Physician subthemes and sample quotes*Subtheme 1: Pain management"I think that GPs think that [patients] shouldn't have pain. Or that the pain is trivial, unless they've had a knee replacement themselves when they know different." [60 M, RHEUM]"Patients shouldn't be worried about becoming addicted to narcotics. It's a very rare individual that this is truly a problem for." [62 M, FP]Subtheme 2: Continuity, coordination and communication"...the very nature is that's what we do in the US is we don't really communicate well, is the lack of consistency and the absence of protocols or consensus. Sadly, you know, the paradigm of health care in the US is that there's such a vacuum." [47 M, PHYS]"It's a bit of a grey zone and there's a fair amount of variability. So I usually try to gather information from [the patient's] surgeon through the patient and then from their physio...: [41> F, FP]Subtheme 3: Access to rehab services"...as you move out away, things become less and less available, and that applies to both community care as well as outpatient programs. And certainly if you're more in the hinterland access becomes a greater issue." [63 M, PHYS]"...transportation is a big limiting factor." [47 M, PHYS]"...it's particularly an issue for seniors that are on limited income. They will try to limit their physical therapy appointments because of finances. So they might not be getting quite as good of a result beyond their surgery." [41 F, FP]Subtheme 4: Different patients, different needs along the continuum"It used to be that people would cope with an awful lot and go soldiering on and feel that this is just the way it was. I'm seeing younger people now who come in and say, 'No, I'm not prepared to do this anymore. You know, I want to be able to do X and Y and so on, and I think I need to have something done.'" [60 M, RHEUM]"There's considerably less need for rehabilitation in our experience with hips and considerably more for the knees. ... we just find that there tend to be more pain issues and more balance and control issues after total knee than after total hip procedures." [63 M, PHYS]Subtheme 5: Outcomes"Balance is a very important issue that needs to be followed... because safety issues and certainly preventing falls is going to be something that's very important to patients as well as the health care system itself." [63 M, PHYS]"It's to get back to work, and then to get back to their activities that they like to do - so golf, swimming. You know, their premorbid activities that they like." [41 F, FP]* Findings based on 1 focus group and 4 interviews. Legend: value. The duration of rehabilitation follow-up care wasalso curtailed by such funding caps.Panelists are identified by age, gender (M = male, F = female) and profession (FP = family practitioner, PHYS = physiatrist, RHEUM = rheumatologistWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 10 of 15Barriers to rehabilitation services included limitedaccess outside urban settings and larger hospitals.Patients typically had fewer if any options for publiclyfunded therapy in more remote areas of Canada. Traveland associated costs with receiving rehabilitation outsideof their home community were problematic for patients."It's been hard because I live so far away. It's about atwo and half hour drive from here to [my rehabilita-tion setting]." [51 M, TKA]"I think the farther you get away from a hospital andwhether you're talking doctors or physiotherapists,oftentimes you do move away from evidenced basedpractices..." [63 M, PHYS]Suggestions for addressing issues related to access andquality of care in rural communities included greater useof tele-rehab and enhanced training for rehabilitationproviders.Theme 6: Back to normalThis final theme reflects the common view that patientswanted nothing more than to return to a sense of nor-malcy after surgery. While being pain-free and mobilewas of primary importance, a more holistic view of 'nor-mal' was repeatedly expressed."I want to get back to be able to walk distances andparticipate in cross-country skiing, snow shoeing andhiking and fitness class, you know, things I did before."[76 F, THA]"...I can only think of emerging from this cocoon ofpain, which pulls you into a very small horizon. And soI really just wanted to get my vitality back." [77 M,THA]"...to do my work is really just life's blood to me." [64 F,TKA]"I was on crutches for 4 years and I have an 8-year-olddaughter, so she'd never really seen me walk withoutcrutches and now I don't have them. So that was reallyimportant. She sees me more as a normal person - nowI can be the parent again." [46 F, TKA]"...you don't want people losing their independent com-munity skills so that they can stay out of nursinghomes." [53 F, RN]There was strong support for a holistic approach toconceptualizing and measuring outcomes from thepatients' perspective."Look at the whole person. The psychosocial aspect isnot always surgeons' strong suit." [63 F, TKA]"...I've had times where I felt that everyone had an areaof expertise and that me as a whole person, nobodywas addressing or even wanting to hear about the totalperson going through this." [64 F, TKA]approaches or the value of using standardized tools inclinical settings. Measures that could be used throughoutthe rehabilitation continuum were thought to be ideal."...it would be nice for people to actually use the sameoutcome measures pre-operatively, immediately post-op... so you could actually see a difference." [43 F, PT]"Some people I believe use the WOMAC. Some peopleuse the Oxford. Some people have their own little com-pilation of different things, and I really don't knowwhat they use off in private practice frankly. So bigweaknesses and we don't have a standardizedapproach to this yet." [63 M, PHYS]Others questioned the value of administering outcometools and questionnaires."...I think that you have got to be very careful abouttrying to quantify it at all. Questionnaires, I've comeacross them before and I think this is stupid! And youput something down, you don't know how it's going tobe interpreted." [81 M, TKA]"I don't ask patients to fill out questionnaires. That'shighly inefficient." [56 M, SURG]When prompted to discuss the need for ongoing fol-low-up or long term monitoring of patients' outcomes,with the exception of surgeons, most felt that surgeons,primary care physicians and AHPs should be involved infollow-up care. Physical therapists were named mostoften as being able to offer an important complementaryrole to the surgeon's evaluation."The same team should follow the same patient,because the [surgeon] now, what's the first thing hedoes? "Okay, your x-ray looks great." But the patientsays, "I'm not walking good." We don't treat x-rays, wetreat people, right?" [42 M, PT]Across all themes were the views that not only werethere different patterns of recovery, rehabilitation andoutcomes following THA and TKA surgery, but also aneed to consider individual variations. Younger or moreactive individuals have different outcome expectationsand rehabilitation needs than older or more sedentarypatients.DiscussionThis paper describes the results of the initial exploratoryphase of a mixed method project to develop practiceguidelines for THA and TKA rehabilitation. A pragmaticapproach was used to identify recurrent issues andimportant concepts for each of the broad discussionpoints in order to inform guideline development andensure stakeholders' views were captured at the outset. Alack of communication coupled with poor appreciationfor each other's roles and expertise appeared to be majorConsistent with the diverse conceptualization of 'nor-mal' as the desired outcome, ways of measuring outcomesvaried greatly with no agreement on measurementissues among our study participants. This was mostapparent with family physician-surgeon and PT-surgeondyads, in less rural communities and between health careWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 11 of 15settings. Trust was also a dominant factor with many sur-geons sharing concerns about the quality and safety oftreatment approaches thought to be provided by outpa-tient PTs; PTs also lacked trust about other PT providers.Lack of trust could potentially be alleviated by improvedcommunication to reduce the misunderstandings, con-flicts, inefficiencies and role confusion that may arise andseverely hamper patient care and outcomes [15,32-34].Different professional training and cultures may explainsome of the disparity in how health professionals com-municate.For change to occur, it will require support at both theprovider and system level [35]. Greater opportunity forinter-professional dialogue is needed to truly enact teamcare within programs and across the continuum of care.Patients' perception of poor and inconsistent communi-cation among their healthcare providers can negativelyimpact patient adherence, confidence, outcomes and sat-isfaction [36]. Participants in this study spoke to the needfor patient-provider communication to improve profes-sionals' understanding of patients' beliefs and preferencesand clear, shared expectations regarding rehabilitationoutcomes of TJA surgery. Disparities in expectations andevaluation of surgical outcomes are well documentedwith surgeons tending to rate outcomes more favorablythan patients [13,14]. The intensity and duration of post-operative pain was common yet unexpected amongpatient participants in our study. Despite this informationbeing readily available through previous studies [37-41],inadequate provider-patient communication and educa-tion may once again be at fault. We found there was bothuncertainty and disagreement among patient and physi-cian participants concerning professional responsibilityfor ensuring adequate pain control beyond the immediatepost-operative period. Similarly, sleep disturbancesdescribed by patients in our study have been previouslyreported [39,42] yet not adequately covered in pre-opera-tive education sessions and virtually ignored during theearly recovery phase. This was problematic for bothpatients and their spouses.Post-operative anxiety, depression, fear and vulnerabil-ity were widely reported by patients and of concern tomany AHPs. While pre-operative psychological factorswere not specifically probed in our study, the literaturesuggests that pre-operative depressive symptoms arestrongly related to post-operative outcomes and satisfac-tion [37,38,41,43]. Study participants recommended pre-operative screening for depression and other factors thatmay contribute to protracted pain and psychological dis-tress and improved surgeon awareness of such psycho-logical factors.and health outcomes of a number of chronic conditionsand surgical procedures [36]. Few studies examining therole of patient factors' in determining TJA need and out-comes have included these attitudinal factors in theiranalyses of important characteristics. Further, currentorthopaedic outcome tools fail to capture the concepts ofpatient attitude, self-efficacy and empowerment [38]despite the evidence suggesting self-efficacy, for example,impacts patient expectations [44], long-term functionaloutcome [45] and adherence to prescribed exercise [46].Poor adherence was a commonly held assumption ofAHPs in our study and felt to be strongly related topatients' overall attitude about their role and outcomeexpectations of rehabilitation. Adherence to therapeuticprotocols is problematic in many studies of TJA rehabili-tation and warrants subgroup analysis to determinewhether higher adherence (e.g., greater treatment dosage)results in larger treatment effects. These findings supportadoption of self-efficacy theory to guide interventions,such as adopting efficacy enhancing strategies like con-tracting and role-modeling to enhance patient's confi-dence regarding the adoption of habits that will supporttheir recovery [47].Our findings show that undergoing TJA surgery magni-fies the need for support in the short term, consistentwith other qualitative reports regarding the value of fam-ily and peer support to patients post-operatively [23].Better social support is associated with lower complica-tion rates, better functional outcomes and higher post-operative quality of life [48]. Patients described feelingsupported by health professionals when they were 'heard'and given sufficient time to have their questions and con-cerns addressed. Similarly, health professionals weremost satisfied with their support efforts when they hadadequate time to spend with the patient. Surgeons on thewhole admitted to having little time to provide the sup-port and guidance sought by most patients and this isequally problematic in Canada and the US.Concerns about poor health professional support werelinked mostly to the follow-up (FU) phase, once super-vised rehabilitation was completed. While the patients inour study had a TJA within the past year, several hadundergone TJA surgery on another joint previously andexpressed their dissatisfaction and feelings of being for-gotten after rehabilitation ended. In a survey and chartreview of 622 THA patients from three US states, only41% reported consistent FU visits with their orthopaedicsurgeons over a 6-year period and 16% reported they hadno FU care [49]. Older individuals and those with lowersocioeconomic status were less likely to receive regularFU. Our study patients suggested they would feel moreEmotional well being including more positive attributes(e.g., self-worth, hope, confidence, empowerment) isincreasingly recognized as an important factor in copingsupported in the year following TJA with regular phonecalls, drop-in FU clinics with both surgeons and PTs, andWestby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 12 of 15group classes to review exercises, monitor progress andaddress any concerns.Personal, provider and system-level factors were identi-fied by our study participants as creating barriers topatients' recovery after TJA. Hoppe et al. acknowledgedrehabilitation as an important tool in reducing costs ofdisability regardless of cause [50]. However, with "therapid proliferation of private rehabilitation services cur-rently operating with little regulation" [pg 18], thoseusing, prescribing and paying for the services are findingit increasingly difficult to determine if in fact, these ser-vices are of good quality, justified and cost-effective [50].In addition to other strategies, routine use of outcomemeasures and practice guidelines is suggested as a meansof justifying and standardizing treatment approaches toaddress the structure, process and outcomes of the reha-bilitation system. Capping the number of visits or dura-tion of rehabilitation may help to control costs but asidentified in our study, such limits were felt to hinder therehabilitation process, ignore individual patient needs,and potentially lead to poorer outcomes and an overallincrease in direct and indirect costs [50].The issue of timely access to surgical care has been apriority of provincial healthcare ministries in Canada forseveral years and the focus of several innovative qualityimprovement strategies [34,51,52]. However, little atten-tion and additional funding have been directed towardaddressing barriers to quality rehabilitative care followingsurgery. Access, including transportation concerns, torehabilitation services continues to be problematic forCanadians and Americans living in more rural settings.Greater use of technology including telerehabilitation(e.g., videoconferencing, remote monitoring) was voicedas a possible solution and deserves further investigationin this patient population [53].Sanderson et al. reported clinicians and patients havedifferent perspectives on outcomes and whereas patients'conceptualization of valued outcomes is broad, healthprofessionals tend to focus on pathology and functionaldisability [54]. We found a similar trend with patientsdescribing a wide range of anticipated and expected out-comes covering many dimensions of health and psycho-social well-being while health professionals, in particularphysicians and surgeons, focused more on impairment,basic function (e.g. walking, using stairs) and surgicalparameters (e.g., fixation of implant). These incongruentviews may play a role in the reported discrepanciesbetween patients' and health professionals' evaluation ofsurgical outcomes in which there are moderate correla-tions at best between patient and clinician assessment ofsymptoms and disability [55].ticipants' negative views on the utility (e.g., meaningful-ness of numerical scores) and feasibility of using suchinstruments in clinical practice (e.g., time to administerand score) contributed to the low rate of standardizedoutcome evaluation. Jette et al. reported that a lack ofsupport (e.g., technology, staffing) and irrelevant andconfusing questions were barriers to routine use [56].Further, the apparent confusion among health profes-sionals regarding what constituted an outcome measuremay have led to underreporting and suggests more edu-cation is needed.Racial differences in patient-provider communicationand the expectations and utilization of joint replacementtherapy have been described elsewhere [57,58], however,we could find no published data specific to the experi-ences of Aboriginal North Americans undergoing TJA.The isolation and lack of access to TJA rehabilitation caredescribed by the one First Nations person living onreserve in our study may reflect geographical, racial orother differences and warrants systematic study, in col-laboration with aboriginal communities.With the overarching views that "hips and knees aretwo different beasts" and subgroups of patients requiredifferent rehabilitation approaches, it is important toavoid a 'one size fits all' approach when designing rehabil-itation practice guidelines for a broad target audience.Strengths of the studyThe credibility and trustworthiness of findings wereenhanced by using a standardized discussion guide, mul-tiple data sources, peer and member checking, indepen-dent coding and maintenance of an audit trail throughoutthe data collection and analyses phases. This study pro-vides new data on specific inter-professional communica-tion issues and barriers to recovery after TJA and sharesinsight from two vastly different health care systems. Fur-ther, it adds to the research on protracted post-operativepain, sleep disturbance and anxiety well beyond theimmediate post-operative stage, which all stakeholdersagree are inadequately and inconsistently managed. Theperspectives of patients and health care providers alikeare important to ensuring the relevance of practice guide-lines, which are extremely time-consuming and expensiveto produce [59] and it is imperative to guideline adoptionthat all viewpoints be carefully considered.LimitationsDue to delays in the ethical review process incompatiblewith project timelines, only one US site was involved. It isunlikely that we heard the diversity of experiences andhealth care delivery issues that are inherent in a countryFew health professionals reported routinely using stan-dardized outcome measures in their surgical and clinicalpractices, despite considerable support for their use. Par-with no universal healthcare program and varied accessto health insurance. As well, the attitudes, functional lim-itations, access to specialty care, and rehabilitation expe-Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 13 of 15riences of uninsured individuals were not captured andmay differ from the individuals in our study. Secondly,physician/surgeon focus groups were challenging to orga-nize and did not include as much practice setting diver-sity as intended. Physicians' views may not be transferableto those practicing in more rural settings with less accessto rehabilitation resources for their patients. Similarly,despite efforts to ensure maximum diversity in patientparticipants, the experiences of less educated individualsand those not receiving formal rehabilitation serviceswere underrepresented.Clinical implicationsThere are several take home messages for clinicians, mostof which are directly aligned with principles of client-cen-tered practice [60] aiming to individualize interventionfor optimal client outcomes as well as best use of thera-peutic resources:• Prior to surgery, ensure patient and provider expec-tations are clearly communicated and realistic;• Prior to surgery, develop a plan for addressing post-acute pain management, psychological distress andsleep disturbances for several weeks following sur-gery;• Use strategies to enhance self-efficacy and empowerpatients to adopt a positive attitude and take an activerole in their rehabilitation;• Incorporate efficient approaches to optimize healthprofessional support and follow-up care beyond threemonths after TJA;• Where possible, engage family members and peersin education, counseling and exercise instruction;• Select meaningful outcome measures and consis-tently use to evaluate effect of interventions through-out the care continuum and across health caresettings.Future research directionsThis study raises a number of questions that could beaddressed through future research including an examina-tion of communication and information technologies(e.g., telerehabilitation) on patient-provider and inter-provider communication and delivery of TJA rehabilita-tion services. Development and testing of a decision aideor screening tool would assist health care providers inidentifying patients at risk for protracted pain, emotionaldistress and functional impairment. Further, there is aneed to design, implement and evaluate the effects of arange of FU programs on patient satisfaction and long-term outcomes after TJA.expectations of individuals who have undergone THA orTKA surgery and the health professionals directlyinvolved in their care. Patients offered a perspective thatdiffered, but overlapped, with the perspectives of healthprofessionals regarding rehabilitation practices and out-comes. Themes arising from all stakeholder groupsrelated to communication, unexpected events, impor-tance of patient attitude and active involvement, profes-sional and social support, barriers to recovery and areturn to normalcy. Awareness of the facilitators and bar-riers to achieving optimal outcomes that emerged fromthis study will help clinicians and administrators in thedesign and delivery of pre- and post-operative interven-tions aimed at helping patients reach their desired goalsafter TJA. Stakeholders' views on rehabilitation for TJAwill inform the next phases of guideline development andensure all perspectives shape guideline priorities, scope,and format.Appendix A - Discussion guide for health professionalsKey questions1a) Think about these services or programs you areinvolved in. What is working well?Probes:What allows (enables) you to provide good care tothese clients?What aspects of your rehabilitation care wouldn't youchange?1b) Still thinking about these rehabilitation services, tellus what isn't working well?Probes:What aspects of care would you change?Are there any concerns that you have regarding reha-bilitation services available to patients following thesesurgeries?What gets in the way (barriers) of providing best careto these clients?2) We are now going to shift from talking about rehabil-itation issues and look more closely at outcomes afterTHA and TKA. What outcomes do you feel are impor-tant following THA and TKA?Probes:Think of both short-term and long-term outcomes,rehabilitation and surgical outcomes,impairment, activity and participation levels3) How should these outcomes be assessed or measuredin the clinical setting?Probes:Do you use any self-report measures? Health profes-sional scored tools? Performance measures?ConclusionsThis qualitative, exploratory study provides valuableinsight into rehabilitation experiences, attitudes and4) Information from these focus groups will contributeto the larger project of developing multi-disciplinary clin-ical practice guidelines for THA and TKA rehabilitation.Westby and Backman BMC Health Services Research 2010, 10:119http://www.biomedcentral.com/1472-6963/10/119Page 14 of 15There are a lot of different ways that we could share thefinal results or recommendations with you. How wouldyou like to get this information? [Results of this fourthdiscussion point will appear in a separate paper.]Probes:What would be most helpful to you?In what format? (written, verbal, interactive, audiovi-sual)In how much detail? (detailed report, summary, quickstudy guide)AbbreviationsAHP: Allied Health Professional; FP: Family Practitioner; FU: Follow-up; KIN: Kine-siologist; OA: Osteoarthritis; OT: Occupational Therapist; PT: Physical Therapistor Physiotherapist; PHYS: Physiatrist; RHEUM: Rheumatologist; RN: Nurse; SURG:Surgeon; SW: Social Worker; THA: Total hip arthroplasty; TJA: Total joint arthro-plasty; TKA: Total knee arthroplasty; US: United StatesCompeting interestsThe authors declare that they have no competing interests.Authors' contributionsMDW and CLB conceived and designed the study. MDW conducted a majorityof the focus groups and interviews and both authors analyzed the data. MDWdrafted the manuscript and both authors read, revised and approved the finalmanuscript.AcknowledgementsThe authors thank the additional focus group moderators Susan Carr, Susan Robarts and Deborah Kennedy for their valuable assistance and all of the study participants for sharing their views and experiences. Lisa Harrison transcribed the audiotapes and Virginia Hayes served as the external peer reviewer. Research assistants Michelle Raglin Block and Osita Hibbert assisted with litera-ture searches, focus group planning and follow-up activities. Michelle Hansen and Nancy Banks helped with coordinating focus groups. Catherine Morley and Karol Traviss provided consultation on focus group methodology and the discussion guide. Donna MacIntyre and Matthew Liang are on Ms. Westby's thesis committee and gave helpful comments on this paper. We also appreci-ate contributions from members of the North American Guidelines for Joint Replacement working group: Dina Jones, Victoria Brander and Pat Carney.This study was part of Ms. Westby's doctoral thesis. Funding was received from The John Insall Foundation for Orthopaedics and the Canadian Institutes of Health Research. Ms. Westby was supported by a Paetzold Fellowship from the University of British Columbia, and training awards from the Canadian Insti-tutes of Health Research (CIHR) graduate scholarship program and a CIHR Stra-tegic Training Fellowship in Quality of Life Research in Rehabilitation.Author Details1Rehabilitation Sciences Research Graduate Program, Faculty of Medicine, University of British Columbia, Vancouver, Canada, 2Mary Pack Arthritis Program, Vancouver Coastal Health, Vancouver, Canada, 3Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada and 4Arthritis Research Centre of Canada, Vancouver, CanadaReferences1. Canadian Institute for Health Information: Hip and Knee Replacements in Canada--Canadian Joint Replacement Registry (CJRR) 2008-2009 Annual Report.  2009 [http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_1519_E&cw_topic = 1519&cw_rel=AR_30_E]. 3. 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Sumsion T, Law M: A review of evidence on the conceptual elements informing client-centred practice.  Can J Occup Ther 2006, 73:153-162.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/119/prepubdoi: 10.1186/1472-6963-10-119Cite this article as: Westby and Backman, Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group study BMC Health Services Research 2010, 10:11951. Markel F, Rafferty C, Rodgers J: Ontario Waiting List Project, Final Report, August 31, 2002.  Ontario Joint Policy and Planning Committee.  Accessed February 9, 2009

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