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The importance of informational, clinical and personal support in patient experience with total knee… Goldsmith, Laurie J; Suryaprakash, Nitya; Randall, Ellen; Shum, Jessica; MacDonald, Valerie; Sawatzky, Richard; Hejazi, Samar; Davis, Jennifer C; McAllister, Patrick; Bryan, Stirling Mar 24, 2017

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RESEARCH ARTICLE Open AccessThe importance of informational, clinicaland personal support in patient experiencewith total knee replacement: a qualitativeinvestigationLaurie J. Goldsmith1*, Nitya Suryaprakash2, Ellen Randall2,3, Jessica Shum2,4, Valerie MacDonald5,Richard Sawatzky6,7, Samar Hejazi8, Jennifer C. Davis9,10, Patrick McAllister11 and Stirling Bryan2,3AbstractBackground: Total knee arthroplasty (TKA) is the most frequently performed joint replacement surgery in NorthAmerica. Patient perspectives on TKA have been investigated in various ways, including finding as many as 20% ofTKA patients are dissatisfied with their surgical outcomes. Understanding the patient experience with TKA broadlyand in relation to patient satisfaction is a key gap in existing literature.Methods: We report on the qualitative component of a mixed methods prospective cohort study examiningpatient experience and satisfaction post-TKA for adults in British Columbia, Canada. Data collection consisted of 45in-depth interviews about individuals’ knee surgery experiences conducted eight months after surgery. Analysisconsisted of thematic coding by multiple coders.Results: Participants’ descriptions of their TKA experiences were primarily concerned with support, or the provisionof aid and assistance. Support was insufficient when their expectations of support were not met; unmet supportexpectations led to an overall negative TKA experience. Support operated in three key domains: (1) informationalsupport, (2) clinical support, and (3) personal support. Key sources of informational and clinical support includedpre-optimisation clinics, surgeons, and physiotherapists. Key topics for informational support included pain, painmanagement, and recovery trajectories. Personal support was provided by family, friends, other TKA patients,employers, and themselves.Conclusions: Patient needs and expectations for support are shaped both before and after TKA surgery. Patientswith an overall positive TKA experience had improvement in their knee pain, stiffness or functioning post-TKA, hadtheir major expectations and needs for support met during their TKA recovery, and believed that any significantfuture expectations or needs for ongoing support would be adequately met. In contrast, patients with an overallnegative TKA experience had at least one major expectation or need for support not met during their TKA recovery,even in cases where they had good TKA outcomes. Suggested interventions to improve the experience of personsreceiving TKA include an expanded patient navigator model, revised pre-surgery educational materials, particularlyaround pain expectations and management, and comprehensive sharing of other patients’ TKA experience.Keywords: Total knee arthroplasty, Qualitative research, Patient experience, Patient-centred care, Support* Correspondence: laurie_goldsmith@sfu.ca1Faculty of Health Sciences, Simon Fraser University, Blusson Hall 10506, 8888University Drive, Burnaby, BC V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 DOI 10.1186/s12891-017-1474-8BackgroundTotal knee arthroplasty (TKA) is the most frequentlyperformed joint replacement surgery in North America,with age and sex-standardized rates of TKA increasingover time [1, 2]. Various aspects of TKA have been stud-ied to improve clinical outcomes and reduce costs, in-cluding reducing surgical wait times and hospital lengthof stay [3–5]. More recently, researchers have investi-gated patient perspectives on TKA, reflecting thecurrent interest in patient-centred care [6–8]. Paying at-tention to the patient perspective—in this case, focusingon improving the patient experience of care—is also akey aspect of the Institute for Healthcare Improvement’sTriple Aim framework. This framework explicitly statesthat it is possible to design health care interventions thatimprove the patient experience while also simultan-eously reducing per capita health care costs and improv-ing the health of populations [9]. In other words,improving the patient experience does not have to comeat the expense of, and can even augment, other cost andquality goals.Research on the patient perspective on TKA employstwo major approaches. The first major approach quanti-tatively evaluates patient satisfaction after TKA, findingthat as many as 20% of TKA patients are dissatisfiedwith their surgical outcomes [10, 11]. Factors found toinfluence patient satisfaction include knee pain, stiffness,and functioning before and after TKA, postoperativecomplications, and patient characteristics including ex-pectations, social support, age, gender, and ethnicity[10–15]. The second major approach qualitatively inves-tigates particular aspects of the patient experience beforeand after TKA surgery, including deciding to have ornot have surgery [16, 17], waiting for surgery [18, 19],pre-surgery pain [20], pre-surgery education [21, 22],post-surgery pain [23], the hospital experience [24], re-habilitative practices [25], managing recovery [26, 27],and returning to physical activity [28, 29]. While it ishelpful that these two approaches to patient perspectiveresearch exist, it is difficult to integrate and more deeplyunderstand their results. The existing quantitative workon patient satisfaction does not usually take patient ex-perience into account and the existing qualitative workon patient experience does not usually take patient satis-faction into account. The qualitative work on patient ex-perience also tends to focus on specific aspects of theTKA experience rather than examining the patient ex-perience broadly. New qualitative and mixed methodsresearch can build from this knowledge base throughallowing for a fuller account of the patient experienceand investigating both patient satisfaction and patientexperience without fully constraining either focus bypreconceived variables and topics. Including a qualitativeapproach can also provide rich data on patient meaningsand preferences [30, 31] and help strengthen decision-making around system resource use and design [32].We conducted a multiphase mixed-methods study[33] to improve our understanding of patient experienceand patient satisfaction following TKA surgery. Thispaper reports on the foundational qualitative work fromour mixed-methods study investigating patient experi-ence and satisfaction with TKA. Our qualitative investi-gation asked patients to reflect on their TKA experiencebroadly, across a variety of aspects of their knee replace-ment experience, and in relation to their self-reportedsatisfaction after TKA surgery.MethodsThe qualitative work reported here is embedded withina mixed-methods, prospective cohort study investigatingpatient experience and satisfaction with TKA. We re-cruited 515 adults aged 19 years or older with a primaryor secondary diagnosis of osteoarthritis scheduled toundergo primary TKA in British Columbia betweenApril 2012 and August 2013. Study participants were re-cruited from the mandatory pre-surgical total joint re-placement education sessions at six sites across theprovince, including at least one site in each of the fivegeographic health regions. Ethics approval was obtainedfrom relevant universities and health regions. For thequantitative component of the study (not reported here),each participant completed a pre-surgery, paper-based,self-administered, English-language, questionnaire andmost completed additional surveys at 6 and 12 monthspost-surgery (91 and 88% of baseline, respectively).Questionnaires included demographics and patient-reported outcome measures about pre- and post-surgerypain, stiffness and functioning, health status, expecta-tions, and satisfaction. For the qualitative portion of theoverall study, we conducted 70 semi-structured, in-depth interviews with 57 purposefully selected individ-uals either once or twice at 8 and 14 months post sur-gery (n = 45 persons interviewed at 8 months, n = 25persons interviewed at 14 months, with 12 of the 25 per-sons interviewed for the first time at 14 months). Thenumber of possible interviews overall and at each time-point was established prior to collecting data due to re-source planning constraints. We anticipated this samplesize, which included 8–10 participants per health region(both urban and rural), would be necessary for reachinginformational redundancy on key themes and key TKAoutcomes and experiences, and for achieving maximumpatient variation [34, 35].This paper focuses on the 45 individuals interviewedabout their TKA experience 8 months post-surgery. Ourqualitative data are rich and multi-faceted; restrictingour initial analytic focus to first-time interviews at8 months post-surgery allowed us to deeply understandGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 2 of 13major issues in patients’ initial post TKA-experience.Additional analysis of the qualitative and mixed methodsdata will build off of the foundation established in thispaper—including understanding the effects of time onpatients’ post-TKA experience and satisfaction—and willbe reported elsewhere.Sample selection and data collectionTo create the qualitative sample from the quantitativecohort, we considered all cohort participants for inclu-sion other than 6-month survey non-respondents andthose having survey completion assistance. We inter-viewed in every provincial region multiple times andinterviewed as many persons as possible who reporteddissatisfaction with their TKA results on their 6-monthpost-surgery questionnaire. We further purpose-fully sampled for maximum variation on other key char-acteristics from our survey data and associatedliterature, including sex, ethnicity, employment status,self-rated health, and various pain, functioning, andemotional health measures. Those purposefully selectedwere approached by letter followed by telephone call toschedule an interview. Interviews took place where con-venient for the participant, including participants’ homesand medical clinics. Interviews were conducted in Englishby experienced interviewers. The semi-structured inter-view guide was designed to understand the individual’sknee surgery experience and outcomes. Interviewee-specific probes were also created based on their answersto the baseline and 6-month surveys. Interviews generallylasted 45–65 min. Participants received an honorarium atinterview completion. After leaving the participant, theinterviewer completed a standardized interview debrief onthe key information learned and suggested interview guiderevisions. The interviews and debriefs were digitally re-corded and transcribed.Data analysisAll transcripts and debriefs were thematically codedusing NVivo software (NVivo qualitative data analysissoftware; QSR International Pty Ltd. Version 10, 2012).The coding scheme was initially developed through twocoders (NS, ER) independently coding the same tran-scripts and debriefs and constructing a thematic codingframework through consensus and input from a thirdcoder (LJG). Remaining transcripts and debriefs werecoded by one of four coders (LJG, NS, ER, JS) with newcodes created when needed to reflect new concepts.Coders met on a regular basis to discuss analysis withkey decisions. Text coded at key codes was also regularlyreviewed and discussed by other team members to fur-ther develop the analysis and provide a check on codingconsistency and construct validity. Once all the tran-scripts were coded with the initial coding scheme,combinations of up to five team members (LJG, NS, ER,JS, SH) met on multiple occasions to discuss key themesand their relationships with the goal of arriving at ahigher abstraction of key themes. Individual coders thenreviewed text coded at key codes to further develop rela-tionships between key themes and identify representativequotations with results further discussed in larger teammeetings. Reflective memos were constructed through-out. Our analysis approach meant that key codes andsignificant portions of interview transcripts werereviewed in multiple ways by multiple team members.This multi-step coding process helped to ensure therigor of our analysis [34, 36].1ResultsWe purposefully sampled 65 participants from the over-all cohort to obtain the 45 persons interviewed approxi-mately 8 months after their TKA surgery. Thirteenpersons declined participation due to worsening healthor other reasons and 7 were not contactable. Post-surgery interview timing varied based on scheduling,averaging 7.9 months (minimum 6.6, maximum9.4 months). Each health region was represented by anaverage of 9 persons (minimum 7, maximum 11). Demo-graphics and other key details of the 45 participants areprovided in Table 1. Given our focus on understandingpatient dissatisfaction, we oversampled from the 15% ofthose who reported TKA dissatisfaction in their 6-month survey, resulting in 58% of the 45 qualitative in-terviewees having reported dissatisfaction (i.e., reportingneutral, dissatisfied, or very dissatisfied on the 5-pointdissatisfaction scale). We secondarily oversampled thosewho indicated that they were uncertain or would not bewilling to have their TKA surgery again if they could goback in time (44% of the 45 qualitative interviewees vs.12% of the quantitative cohort). Our qualitative sampleotherwise roughly mirrors key distributions in the over-all cohort, with over half of the sample being women,having married or common-law status, a household in-come below $60,000, or North American or Europeanethnicity. Over half of both our qualitative and cohortsample also were experiencing their first knee surgery orhad waited more than 12 months from the onset of theirknee symptoms and first seeing their TKA surgeon.Participants’ descriptions and sense-making of theirTKA experiences were primarily concerned with theprovision of aid and assistance, a concept we label “sup-port.” Support was deemed to be insufficient when theirexpectations of support were not met; unmet supportexpectations often led to an overall negative TKAexperience. Support expectations were both formed inadvance of surgery and in response to emergent needsafter surgery. TKA patients’ experiences in this studyprimarily operated in three key domains: (1)Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 3 of 13informational support, (2) clinical support, and (3) per-sonal support. These domains interact with each other(Fig. 1) and a deficiency in one domain can sometimesbe compensated for by another domain, as explainedbelow and through illustrative quotations from variedparticipants (Tables 2, 3 and 4).Informational supportAll participants noted the importance of informationabout TKA preparation and recovery. Patients receivedinformation through formal clinical sources, such aspre-surgical education sessions and health care pro-viders, and informal personal sources, such as friendsand family, the internet, and, when applicable, their ex-perience with having already received TKA on theirother knee.Each participant identified the pre-surgical educationsessions as a key form of informational support from aclinical source. The provided information was often alsodescribed as insufficient—many participants wantedmore information than routinely provided at the sessionsto be better prepared for TKA recovery and to activelyparticipate in their own care. Some participants furthersaid that their education session information was notmeaningful as it was difficult to understand or remem-ber the instructions or it was difficult to reconcile thedifferent messages they received from different pre-senters. This information was further complicated byhaving hip-replacement patients at the same educationsession as knee-replacement patients. Participants alsoreflected on how they were overwhelmed, anxious, orscared before the surgery, which made it challenging toretain information from the education session.Surgeons were both expected and actual key clinicalsources of information about TKA preparation and re-covery, although many participants wanted more infor-mation from their surgeon than they received. Multiplepatients described their visits to the surgeon as too“matter of fact,” emphasizing checking physical function-ing. Participants described surgeons as not readily pro-viding wanted information and not having or makingtime to answer questions. This situation was exacerbatedby patients feeling overwhelmed by their visit to the sur-geon, which often led to patients not asking their pre-pared questions. Participants noted and appreciatedwhen a surgeon took time to provide sufficient and help-ful information. A few participants recounted that eventhough their TKA outcome was not as good as they ex-pected, the time and information provided by their sur-geon both before and after the surgery improved theirTKA experience. Regardless of the surgeon’s ability toprovide information support, patients typically saw theirsurgeon a few times following their surgery whichTable 1 Participants’ Descriptive Details (n = 45)CountAge, average 65 yearsSex Female 30Male 15Marital status Married orcommon-law34Widowed 3Single, divorced orseparated8Household income < $40,000 12$40,000 to< $60,00010$60,000 to< $80,00010$80,000 or more 10Missing 3Education High school or less 19College/technicalschool12Undergraduatedegree3Graduate degree 8Other 2Missing 1Ethnicity North American 33European 8South Asian 2Central/SouthAmerican1Other 1Received TKA surgery on first or second knee First knee 32Second knee 12Missing 1Time between knee symptoms and first timeseeing surgeon<6 months 9≥6 to < 12 months 9≥12 months 25Do not remember 2Satisfaction with TKA surgery results, self-evaluated 6 months post-surgeryaVery satisfied 8Satisfied 10Neutral 15Dissatisfied 9Very dissatisfied 2Missing 1Willing to have TKA surgery again, self-evaluated6 months post-surgeryYes 25Uncertain 12No 8aThe 5-point satisfaction scale can also be reduced to a 2-point satisfactionscale where satisfied is composed of those who answered “very satisfied”or “satisfied” on the 5-point scale and dissatisfied is composed of thosewho answered “neutral,” “dissatisfied” or “very dissatisfied” on the5-point scaleGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 4 of 13restricted patients’ ability to use the surgeon as an infor-mation source.Other health care providers could be valuable sources ofinformation post-TKA but were inconsistent sources of in-formation support. Many participants recounted that theirfamily doctor was no longer involved once the decision tohave TKA had been made. Some sought advice from theirfamily doctor after their TKA surgery if their surgeon wasunavailable but found that their family doctor provided noor limited information. Physiotherapists provided informa-tion about post-TKA exercise and recovery and ofteninteracted with participants multiple times after the sur-gery, but some participants still felt that the exercise infor-mation was not comprehensive enough. One hospital hadphysiotherapists make home visits to TKA patients aftertheir surgery which participants found helpful for under-standing their recovery in their home context.Talking to other TKA patients was another form ofinformational support. Although a few participantsexpressed a preference for dealing with things on theirown, the majority of participants stressed the import-ance of talking to other patients with previous TKA ex-perience. Patients shared information about surgeons,types of treatment, exercises, and healing and recoverystrategies and trajectories. Such information sharing wassometimes a response to insufficient information fromclinical sources.The most frequent type of informational support iden-tified as needing improvement was information on painexpectations. Many participants expected that the sur-gery would alleviate their pain and were surprised andunhappy when they experienced intense pain after theirsurgery, particularly when pain was long-lasting. A fewpeople thought that when the arthritis was “taken out”of their knee with the surgery that their pain would becompletely gone. Some participants said that their pre-surgery education session did not tell them they wouldexperience post-TKA pain; others said that while theireducation session did provide information about pain,not enough information was provided. Participants ontheir second knee TKA experience illustrated theempowering nature of this knowledge, recounting thatthey knew this time around to expect significant painand to exercise through it. Despite their interest in hav-ing more information about pain in advance of their sur-gery, some participants felt that fully forewarning othersmight stop them from having surgery.Participants also expressed concern about inadequateinformation regarding pain management. Pain manage-ment education was sometimes offered by physiothera-pists during rehabilitation. Some family doctors providedassurance about pain medication addiction concerns andhome care nurses provided education about icing tech-niques. Despite the existence of these forms of assist-ance, inadequate pain management information supportwas a frequent issue for participants. When reflecting onhow they could have better learned about pain and painmanagement, many participants suggested that TKA pa-tients should have access to a “go to” clinical person toanswer patient questions. The clinical expertise of thisperson was left unspecified, although many participantsalso expressed that surgeons should be more available topatients to discuss pain and other recovery concerns.Multiple participants wanted to understand the varietyof TKA recovery trajectories so they could be assuredthey were on some sort of a track to recovery, even if itwas not the ideal track or an ideal recovery. To supple-ment the inadequate recovery trajectory information,many participants compared themselves to other TKApatients they knew. When their recovery experience wasworse than others’ experiences, participants did notknow how to make sense of this mismatch and wantedclinical support in understanding their problems. Manyparticipants suggested that a formal patient buddy pro-gram would be helpful, where patients could be pairedwith a former TKA patient to normalize the recovery ex-perience. Some participants had already started doingthat for others in an informal way.Fig. 1 Key domains of support in patient experience of total knee arthroplastyGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 5 of 13Table 2 Informational support illustrative quotes(1) Pre-surgical education session as a source of informational support“The [education session] is really informative….They prepare you foreverything. If I went to the hospital without this program and wokeup with my leg looking and feeling the way it did, I think I mighthave wanted a new limb.”“I went to all the pre-surgery meetings…But nobody ever really said,‘This is not a real knee. This is not going to be the same as your otherknee was. There will be limitations.’… I did read all the literature butnowhere did I see that said.”“The [education session] was pretty good but not good enough. Idon’t think we really got enough warning about how muchassistance you need afterwards…But maybe they can’t tell you whatto expect because there’s so many differences in people too—itwould take forever and maybe scare some people needlessly.”“I still don’t think that they explained how painful exercises are goingto be at the pre-op session. You are told, but it doesn’t sink in. I thinkthat should really be pushed. It is going to be painful but you can’t doany damage. Like, once the knee is in place, you can’t really harm it.”(2) Surgeons as a source of informational support“The one you really want to rely on is of course the surgeon. [Youwant to ask] ‘What did you do to me?’ or ‘What are you going to doto me?’““They are always in a hurry,… [My surgeon] showed me the x-ray.‘And this is fine. It’s fine. You’re going to be fine.’…You are just anumber and you just go and it’s quick, quick, quick.”“I think the hardest thing was [my surgeon]’s so hard to talk to…Ithink that probably was a lot of my problem, not feeling like I wasgiven enough information.”“I only saw [my surgeon] a few times…a very nice person, veryfriendly to me. I wish I could see him more to get moreinformation…but they have so many patients, [the visit is] so veryfast.”“The surgeon, when I first met him, I thought, ‘Boy, that guy’s got nopersonality.’ When I got to know him I realized he does, but he’s abusy man. They are very busy. He’s willing to answer any questionsbut if you don’t have the questions to ask, how can they answerthem?”“I wanted to know why I was so numb in my knee and [the surgeon]didn’t answer me. He just said ‘You’re going to have to give it time.’““You have to be really prepared and aware what you want to ask.You got to go in prepared because you get a little nervous. You getintimidated by these guys.”“[My surgeon] walked us step by step. He showed me what thesurgery would do and what it would look like and then he showedme the x-rays of my knee and he explained everything that wasgoing on…I can’t praise him enough.”(3) Other health care providers as a source of informational support“My family doctor is fine but he—perhaps because of the little bitmore complexities in this case, he really didn’t have any opinions ofhis own about things. He really deferred everything to the surgeon.”“When I went for physio, the therapist kept on saying, ‘It’s going tobe a year.’ And so that gave me hope too because when I first wentthere, I thought I’d be better already. I would have thought ‘A monthhas gone. What’s wrong here?’““The [physiotherapists] here tell you to get on with the exercises anddon’t back off on that. They did point out quite emphatically that ifyou have pain, use the medication. Don’t back off on the exercisebecause of pain. If the knee hurts, take a pill. Don’t stop bending it.”Table 2 Informational support illustrative quotes (Continued)“The physiotherapists set you up with a program. You’re only allowedto go for three visits. So you are cramming in three visits all theseexercises which you are supposed to do. And rather than followingup, people just go back to their old patterns because no one ischecking up.”(4) Other TKA patients as a source of informational support“We are all comparing scars [saying] ‘Oh, your scar is so much nicerthan mine.’”“If I had met [another TKA patient] who would have told me thehonest truth—‘This could happen’ or ‘I had this happen’ or ‘There’squite a bit of pain at first,’ you know, this sort of thing. I might havehad more questions to ask [the surgeon].”“My girlfriend is getting it done so she was asking me differentthings… I did tell her to go to all the physio…. I said that throughother people that were in physio, I did hear that [her surgeon] was agood doctor.”“I think seeing where other people are at [physiotherapy] gives youincentive too and makes you say, ‘I should be able to do this.’ Or ‘Ishould be working at it harder.’”(5) Informational support for pain expectations“I don’t think it’s stressed enough and I don’t think I ever read orheard before I had the surgery that the pain is not going to go awayfor a year. I thought [it would go away] in a month”“I thought it would be better than it is…The twisting pain I’m hopingwill get less but it’s still pretty severe…I thought my knee wouldn’thurt when I walked down the stairs, and maybe it won’t, given somemore time. I am constantly told ‘Wait, wait, wait.’ so, I’m waiting. I justexpected less discomfort after this period of time.”“The meeting at the hospital before you went in for surgery wherethey were explaining kind of what is going to happen. And they keptsaying, ‘Oh, yes, you’ll have a little pain.’ I wish they had been a littlebit more honest as to the amount of pain.”“I got mixed messages particularly when I went to physio. Oneperson would say to me ‘Oh well, don’t do it if it hurts.’ Anotherperson would say ‘Well, that’s the way it is.’…It’s a bit confusing.”“[After my first knee replacement] I was afraid to push it too hardbecause I didn’t know if I was going to do damage because of thepain. This time [for my second knee replacement] I knew I couldn’treally do any harm…I think probably for a lot of people the pain withthe exercises, they are not prepared for it.”(6) Informational support for pain management“I’m frustrated [by the pain]… I’ve been back to my GP a few timessaying, ‘Come on, there’s got to be something.’ ‘No, you are doinggreat.’ I go to physiotherapy. He says, ‘Oh, look at the movement inyour leg. You are doing terrific.’ Okay, I am doing terrific but it hurts.”“The physiotherapist said it’s breaking down scar tissue which tendsto form. You have to break it down to get the range of motion. Andthat gets uncomfortable. So bear with it. Use the pain killers asnecessary but don’t let pain restrict your recovery.”“I kept on talking to [my family] doctor saying, ‘I don’t want to get[addicted].’ They say, ‘Take the pain medication, the pain medication.Manage it so you can move it.’ And I said, ‘Well, I don’t want to getaddicted to it.’ ‘Oh, don’t worry about that, don’t worry about that.’But I did worry about it.”“I think that if I’d had somebody I could call, even a couple of timeslike now and say, okay, it’s seven months, I’m in pain, the swelling isreally bad today, what the hell do I do?”Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 6 of 13Other areas participants identified as needing add-itional information support included post-surgery issueslike knee clicking, infection and scarring; post-surgeryexercise and functioning; and alternative and supple-mentary rehabilitative options.Clinical supportPatients expected that surgeons would be key helpers formaking sense of their TKA experience but few partici-pants were provided with this clinical support. Manyparticipants wanted more personal and higher quality in-teractions with surgeons where ideal interaction exam-ples consisted of both emotional support and supportwith their health needs, including information support.Most patients wanted a surgeon who was both a skilledtechnician and an empathetic individual, yet participantsoften described surgeons as mainly providing surgeryspecific support, with little to no effort at building rap-port or making the patient feel like an individual. A lackof personal interaction often impeded patient reassur-ance and many participants had a hard timeunderstanding why their questions and concerns wereunanswered or diminished.Patient sense-making was further challenged by mis-matches between the patient’s and surgeon’s perspec-tives. The first type of mismatch was where the surgeonlacked empathy for the patient’s experience, includingtimes that patients learned for the first time post-surgerythat their knee should have been replaced much soonerthan it was and their post-surgery pain indicated a lon-ger recovery timeline. Another type of mismatch wasdemonstrated when the surgeon did not appear to beseriously investigating the patient’s unresolved post-surgery problems, which often left the patient frustratedand confused. The lack of availability of the surgeonpost-surgery was a third mismatch and was sometimesinterpreted by the patient as the surgeon not caringabout or not believing the patient. Some participants re-ported that mismatches resulted in losing trust in thesurgeon and expecting that future interactions would beas unsatisfying as in the past. Participants sometimes at-tributed mismatches to the power imbalance betweenthe surgeon and patient, describing the surgeon as con-descending or arrogant.Physiotherapists and physiotherapy services providedkey clinical support. Physiotherapy helped patients re-gain mobility and resume their regular activities. Manyparticipants felt that a “good physiotherapist” was criticalto properly recovering from surgery. Good physiothera-pists had effective communication skills, treated eachpatient as a person, had time for patients, and tailoredthe services to the patient’s needs, including extendingthe number of sessions provided to the patient.Hospital-based physiotherapists were valuable due totheir proximity to the surgeon, although some private-practice physiotherapists were valued for their flexibleschedules. Physiotherapy was also a place where patientscould share information, interact with others, andbenchmark their recovery with other TKA patients.A few patients received inadequate physiotherapy sup-port, usually resulting from not getting scheduled forphysiotherapy until long after their surgery. Most ofthese examples were from patients having their surgeryoutside of their local catchment area and then trying toreceive outpatient physiotherapy close to home, al-though a few participants were not scheduled for out-patient physiotherapy even when their surgery was attheir local hospital. Some of these unscheduled patientswere assisted by persons within the health care systemTable 2 Informational support illustrative quotes (Continued)“There is nobody to talk to. You call the surgeon and unless there islike a major problem they don’t want to hear it from you because allthey care about is what the x-ray shows and the x-ray shows perfect.It’s fine. The GPs, they didn’t do the surgery so it’s more pain control—like,‘Do you want stronger pain pills?’ And I said no. I don’t want to just coverup the symptoms. I need to know what is going on. So you can get onthe internet and check things, but there is nobody to really talk to aboutthe pain, the swelling.”(7) Informational support about recovery trajectories“Unless I’m the exception. I don’t know if everybody has [theseproblems]. ….It would be nice for them to say, ‘Okay. This is thescenario. Some people may get full movement back but some peoplemay not,’ you know. If they could let you know those options butthey didn’t.“My brother had both of his [knees] done two years previous and afriend of mine had hers done and the neighbour across the streethad hers done with the same doctor that I got it done with so I kindof knew what to expect.”“I should have sat down with [my neighbour] longer because he’shad his knees done…I’d like to have a phone-a-buddy, to phonesomebody that’s had an knee operation the same time I did and ask‘How’s your recovery going?’“(8) Informational support about other post-surgery issues“Nobody said anything about the clicking…It kind of [worried me]because I was wondering if there was something wrong, that itshouldn’t be like that. And, of course, I got told it was quite normal.Everybody’s knee pretty much does it. And he explained why, whichwas good. Once I got the information and I understood that it wasn’ta big deal, it was fine.”“[The surgeon should] take some time to really explain to somebodywhat’s really going to happen, like, what your expectations should be.You may not have the pain you had before but this knee is going tomake noise when you walk. This knee is going to feel like it’scrunching inside your leg. You’re going to have quite an ugly scar.You’re knee won’t be shaped the same as your other knee anymore.”“This [part of my knee] is still numb. I asked about that. [My surgeon]said, ‘Oh, it may never come back.’ It looks very different than myother knee. I know I’ve got ugly knees but it’s small. This is smaller. Itgets warm still and that’s something the physio said is not good…[My knee is] a lot better than it was but it’s certainly not as good as Iwould like it to be.”Italics indicate word was emphasized by participantGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 7 of 13to eventually get physiotherapy, although the patientshad to first advocate for themselves to multiple points inthe system before finding an advocate in the system.Although they played a minor role in post-TKA clin-ical support, family doctors sometimes assisted with painmedication or provided additional recovery advice, suchas suggesting other rehabilitative activities like massagetherapy and water exercises. Other family doctors werereluctant to provide information; participants perceivedthis was because the family doctor did not want to getinvolved in the “surgeon’s business.”Personal supportFamily and friends were important sources of personalsupport for a variety of activities. Participants recountedneeding much assistance with activities of daily livingafter TKA surgery. When first sent home from the hos-pital, participants described needing assistance turningover in bed, bathing, using the bathroom, and usingstairs. Participants were initially unable to drive aftersurgery; some had family or friends drive them to healthcare appointments while others relied on public trans-portation. Family and friends also went grocery shoppingand prepared meals. Some family members—malespouses/partners in particular––and some friends werenot capable of providing personal physical support. Rea-sons for this lack of capability included: being anxious,feeling unskilled, not understanding what support wasneeded, their own physical impairment, and being busyin their own lives.The physical support provided by family and friendsoften also helped patients feel emotionally supported.Participants also described explicit emotional supportprovided by family and friends through visiting and go-ing out for meals or social activities. Other TKA patientsalso provided key emotional support through validatingparticipants’ feelings and providing encouragementabout recovery.Table 3 Clinical support illustrative quotes(1) Surgeons as a source of clinical support“[My surgeon] has a good reputation. The hospital thinks the world ofhim…So I went to visit him and it was just a great match. He coversall the bases and tells you everything. There’s no secrets, no bigsurprises. He said if everything goes well, I’d only be in the hospitalthree days. That’s what it was.”“[My surgeon was] not really reassuring or anything. Very matter offact…very ‘It’ll be this way. If that doesn’t happen, this will happenand we’ll do it that way.’ And basically that was it…he wasn’t verypersonable…It wasn’t any kind of conversation. It was very quick.”“[The surgeon] said, ‘I just wish I had more patients that were like you,that were healing quicker.’…I felt good because he did a good joband I felt good because I’d done a good job doing my exercises andeverything. It was a win for both of us.”“[My surgeon] is so caring…even when I am crying he is like, ‘Oh,we’ll do this. We’ll get through it.’…I knew that he was going to helpme.”“I think the minute he heard or saw my psychiatric file, I think heprobably thought this person isn’t worthy of a knee replacement.”“The surgeon is useless to get information out of…6 weeks [after thesurgery] I went in there and he said to me something which I didn’tunderstand and I’m sorry I never pursued it.”“I’d saved up these questions. I wanted to know if it was cement orscrewed in. I wanted to know if the scar was the way it should be, ifthe numbness should be there. He answered my questions but in avery different way than I would have assumed he’d answer them. Iwould think that rather than make it sound so ordinary—this isn’t anordinary thing.”(2) Physiotherapists and physiotherapy as a source of clinical support“Physiotherapy is the one thing you can count on.”“I went to physio twice a week and each week I could tell, getting inand out of the vehicle and walking into the hospital, I could feel thatit was getting stronger.”“[The physiotherapist’s] attitude was all help. If you needed help, shehelped. Very positive, saying things like ‘Work through the pain,you’re doing great, just push a little harder.’”“I went to rehab at the hospital and I could have done it as long as Iwanted. They were fantastic. And it was all covered. I never got askedto pay for anything, it was all covered.”“One of the things they worked on [in physiotherapy] that I foundvery helpful, so did other people, was they developed a camaraderie,this big family get-together type of thing, to talk to people, comparenotes and get a little encouragement from patient to patient. So itwasn’t just an isolated one-on-one therapist to patient. There was alot of dialogue between patients.”“They were sending in a referral to [hospital name] for physio. I wasgiven a phone number to call. So the first week home I called andthey said there is nothing available yet…I was getting very desperateand in about the fourth week I started calling other hospitals… I wasalmost in tears. I was at my wits end, didn’t know what to do. Andthe woman in reception there said, ‘This isn’t acceptable, I’m going totalk to the physio and I’m going to call you back. I’m sure we will fit youin.’ She phoned back the next day…Without them—if they would havetaken the same attitude as everybody else—I probably still wouldn’t beable to bend my knee.”(3) Family doctors as a source of clinical support“I have a GP who has been with me through the whole painmedication process, to the reduction of opiates, to the pre-surgeryconsult through the referral. He took my staples out at the end of theTable 3 Clinical support illustrative quotes (Continued)surgery. He followed me along through the recovery process post-surgery to make sure there was no infection. He followed alongwith the physiotherapist’s recommendations.”“I think my GP does know [that I still have unresolved pain in myknee]. I think he does. He knows I am under a lot of stress, acombination of the pain and being a caregiver. But there is nothinghe can do. He can only give me so many Prozac and so manypainkillers.”“I did go to the GP about my knee and asking him for advice onwhat I can do because the system isn’t doing it. And he suggestedAquafit.”“I don’t talk to my family doctor about it because he’s not interested.That’s the surgeon’s problem. [My family doctor] doesn’t want to getinvolved.”Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 8 of 13Participants further recounted the importance of selfsupport. Many undertook pre-surgery preparation oftheir home for post-surgery safety and convenience.Many felt highly responsible for their own healing andrecovery and expressed this responsibility through creat-ing pre- and post-surgery exercise routines, undertakinglifestyle changes such as dieting and losing weight, main-taining hobbies, and keeping a positive attitude despitepost-surgery challenges. Self-support was also expressedthrough advocating for better treatment or extra atten-tion from providers and specifying from whom they re-ceived care.Employers could be additional sources of personalsupport for working participants. Many working partici-pants described their employers as supportive and un-derstanding of their situation, including allowing themto work at home. Some participants also had insurancethrough their employer that covered all or some of theirhealth care expenses, such as extra physiotherapy. Otherworking participants had negative experiences with theiremployers, including being unable to take enough sickdays for recovery and having to return to work withminimal physical accommodation.DiscussionWe found that patient experience of TKA can be con-ceptualized in terms of patient needs for informational,clinical and personal support, where patient expectationsfor support is shaped both before and after TKA surgery.Patients with an overall positive TKA experience hadimprovement in their knee pain, stiffness or functioningpost-TKA, had their major expectations and needs forsupport met during their TKA recovery, and believed thatany significant future expectations or needs for ongoingsupport would be adequately met. In contrast, patientsTable 4 Personal support illustrative quotes(1) Family and friends as a source of personal support“My son has been very helpful. He’d do the shopping or the laundryand cleaning or drive me places to my appointments.”“My wife and daughter were trying this idea of one on each side andthen three people abreast across can’t go up the staircase. But ournurse friend knew how to negotiate all that.”“There are people here in the co-op. They were only a phone callaway if I needed anything. They’d phone, ‘I’m going grocery shop-ping. Do you need anything?’““I needed to get to a physio…I didn’t want to impose on [my friends]to drive me over there and sit for an hour. But I couldn’t really trustmy husband because he’s got dementia.”“The whole surgery thing made [my husband] very anxious. So hisdaughter had come to stay with us for a couple of days…and once Ihad the surgery she left. So I had to get back on my feet almostimmediately and I was driving within 10 days, you know, could justbarely move my foot but I could move it enough, to drive the car.”“[My friend] said, “Well, we can’t go walking or do anything becauseyou’re an invalid. You can’t walk.’ So my social life has gone downhill.”“Our church family was so supportive too…It’s incredible, the cards,the phone calls, the meals I would get…it shows they care. I thinkthat is such a huge part of recovery.”(2) Other TKA patients as a source of personal support“[My friends who had knee surgery] knew what it was all about andthey told me how important it is. ‘Do your exercises. Don’t put themoff.’ And when I could see how well they were doing, it encouragedme.”“I talked to more people that are waiting to have [their kneereplacement] done to encourage them. I find that a lot of people arescared and I try to encourage them because I say you just won’tbelieve how you feel the day after your surgery to have that painanymore.”“I spoke to about half a dozen people that had it and they were allwalking around, they were fine, they were back to playing sports anddoing whatever.”(3) Self as a source of personal support“I was prepared and knew you need to have a toilet riser, you needto have a cane, you need to have a walker… I even went to the RedCross and got everything there.”“One of the things I learned [before surgery was] change your lifebefore [surgery] and you’ll heal better. Which I did. I stopped drinking.I’m not a big drinker but I totally stopped alcohol.”“I was very good about doing all my exercises every single day, twicea day as they told me. I went to physio on my own after I ran out ofphysio at the hospital, which I have no coverage for so that wasanother three hundred and fifty bucks [out of my pocket.]”“I was also an active participant in the process which I think has gotto be one of the keys to it. You can’t be a passive person and letthem kind of do things to you because ultimately you have to beresponsible for your own rehabilitation and recovery, be involved in itright from the very beginning.”(4) Employers as a source of personal support“The union is supportive. The company is supportive… People try tobe as accommodating as they can if somebody needs help.”Table 4 Personal support illustrative quotes (Continued)“So I postponed going to work for that month, plus I work for adoctor and she knows what is involved, and she said, ‘No, definitelytake another month off, take the time that you need.’”“I am not at full time yet. I am working five hours a day. I hoped toincrease that but my knee would keep flaring up and I couldn’tattend at all. Work has agreed to rent a recliner. Sometimes my kneeis swollen and I need to keep it up. That’s the difficult part.”“We have a really good extended health care program. They coveredeverything….I had to get a pool pass. He just said, ‘Just send us areceipt. We’ll cover you.’”“I’ve had some issues with my employment, about getting back towork and its very aggravating and its very stressful…after twomonths they were phoning me, ‘You can come back to work.’… Butthen I said I also have physio. There’s where they have a fine line: yougo to physio and now you’re on sick time again.”“I went back to work and did full time for three months and I justcrashed. I couldn’t do it anymore… My manager was…unsympathetic.”Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 9 of 13with an overall negative TKA experience had at leastone major expectation or need for support not metduring their TKA recovery, even in cases where theyhad good TKA outcomes. Patients with overall nega-tive TKA experiences sometimes also believed thatany significant future expectations or needs for on-going support would not be met in an adequate way,usually based on having already experienced multipleinstances of inadequate support.Having appropriate support could help address post-TKA pain, functioning or stiffness problems, which wereidentified as significant challenges by several participants.In all cases where our study participants reported havingpost-TKA knee issues, having caring and informative clin-ical input, especially from the surgeon, made the partici-pant more likely to report positive experiences than wouldbe expected given her or his knee problem. Participantswere clearly comfortable with knowing that recoverywould take time, that not everything would work out per-fectly, and that they had a role to play in having a goodTKA experience. In other words, participants were verycomfortable with taking on their part to support a positiveTKA outcome, even without perfect knowledge of all thatwould be expected of them. Along with assuming theirown responsibility, participants expected health care pro-viders and the health care system to support them toachieve positive TKA outcomes across a variety of patientexperiences, including difficult, challenging, or unusualpatient experiences. Where health care providers did notsupport this approach—such as telling the patient thateverything is fine with their knee when the patient thinkstheir knee is far from fine—our study participants chal-lenged this thinking, suggesting that clinicians and the sys-tem needed to expand the boundary of when they endtheir support for the patient.Participants in our study were clearly asking for clini-cians and the health care system to adopt a more patient-centred approach across their surgery and recoveryexperience. Improving patient-centredness is the responsi-bility of all involved in the health care system [6, 8, 37];surgeons are neither the sole problem nor the sole solu-tion, even though surgeons played a key role in partici-pants’ narratives. The current system structure positionsthe surgeon as one of few resources the TKA patient canturn to for problem-solving, which carries with it all of thelimitations and vulnerabilities of single node systems,including bottlenecks [38]. This does not need to be thesystem structure of the future. Orthopedic clinics and hos-pitals could offer additional options for patient problem-solving. One intervention that could fill this gap would bean expanded patient navigator for TKA patients, wherethe patient navigator role is held by a clinician such as anurse practitioner who can provide patient care and edu-cation and liaison with surgeons, physiotherapists, primarycare, home care, and social services. Other possible gap-filling interventions could expand the offered support be-yond the health care system, such as implementing the“TKA buddy” program advocated by participants in ourstudy, where current TKA patients are paired up withanother current or previous TKA patient to provide avenue for informational and social support. Our studyparticipants also suggested that pre-surgery educa-tional materials could be improved, including sharingthe recovery stories of multiple TKA patients to illustratethe variety of TKA patient trajectories and provide an-other form of informational support, particularly aroundbenchmarking and normalizing individual situations andexperiences.Our results resemble other qualitative studies showingthat a mismatch between patient expectations and TKAoutcomes are associated with negative patient experi-ences and patient dissatisfaction with knee replacement[24, 26, 27, 39–42]. One quantitative review also cameto the same conclusion [14] but a second quantitativereview found that no such relationship after adjustmentfor confounders [43]. Although these two quantitativereviews used a different set of studies, we suggest theirdifferent conclusions result more from the inadequateconceptualization of patient expectations, particularlyaround post-surgery care. Our study showed that patientexpectations around TKA outcomes were not always re-lated to the knee itself. Patient expectations, particularlypost-surgery, were also related to receiving clinical sup-port for resolving knee problems. Participants in ourstudy who reported problems with their knee and yetwere told by their surgeon that their knee was fine didnot have their expectations of clinical support met. Simi-larly, managing patient expectations is in part about pro-viding appropriate and sufficient information to thepatient throughout the TKA process [44]. Our study par-ticipants’ comments about how more advance knowledgeabout pain expectations and management would havemore positively shaped their experience is one examplewhere information support can lead to good manage-ment of patient expectations. Information support canalso lead to shared decision-making, or active participa-tion by both patients and clinicians in care decisions,which has a variety of positive outcomes, including im-proved patient experience, satisfaction, and other out-comes [22, 45, 46].Our results also resemble other qualitative studies indocumenting and specifying the importance of a varietyof types of support, although our study differs from pre-vious literature by enhancing, elaborating and unifying avariety of expressions of support as conceptualized inother patient experience studies in joint replacementand osteoarthritis. For instance, Westby and Bachman’sinvestigation of rehabilitation practices and outcomesGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 10 of 13from the perspectives of hip and knee replacement pa-tients and providers found that “[rehabilitation] takes allkinds of support.” Although they did not specify categor-ies of support within the “all kinds” description, they didprovide examples that directly map onto our study’s in-formational, clinical and personal support categories[25]. Another qualitative study found that communica-tion about multiple aspects of the care process was a keyfactor in the patient’s hospital experience with knee andhip replacement [24]. A third qualitative study foundboth patients and clinicians identified that cliniciansneeded to provide more consistent clinical attention andimproved information to improve care of people withosteoarthritis [47]. Other qualitative and quantitativestudies of knee and hip replacement experiences identifythe importance of patient education, care continuity,pain management and other physical, psychological andsocial aspects of the patient experience [48, 49]. Ratherthan replicating the existing literature’s current approachof listing themes and categories within a single study, fu-ture work could use our study’s support framework asan impetus for a deeper understanding of the kinds ofsupport important to patients and the interrelationshipsbetween these types of support.Using a qualitative approach means that our study islimited in its ability to generalize to populations as quali-tative research can only be generalized to theory ratherthan populations [34]. However, having interviewedpeople from across the province, with purposeful sam-pling guided by advance knowledge of the variationacross our large cohort sample, means that our ability totheorize is rich and varied [50]. Our results contributerelevant insights in understanding the patient experienceand the related needs for different types of support for avariety of TKA patients.This study interviewed participants 8 months post-surgery; different information and perspectives may havearisen had we interviewed people closer to their surgery.However many participants described their TKA experi-ence across time, including shortly after surgery. Weonly explored patient experience with TKA for those pa-tients who can read English and were well enough toparticipate in an in-depth interview. Our overall studyand the qualitative portion included few persons fromracial and ethnic minority groups. We are unable to saywhether our results apply to patients more marginalizedor challenged in their TKA experience through languageor racial or minority status [51, 52]. These results do notexplore the experiences of those who never receive TKAsurgery in the first place, either by their decision to nothave surgery or by being less likely to be offered surgery[53]. Nevertheless, our study’s results provide insightinto a wide variety of experiences and the importance ofvarious types of support in TKA patient experience.ConclusionsThe three domains of support identified in thisstudy—informational support, clinical support, andpersonal support—can provide guidance for cliniciansand other health care system decision makers onareas needing improvement for patient experienceand satisfaction with TKA surgery. Clinicians andother decision makers should also keep in mind thatpatient needs and expectations for support are shapedboth before and after TKA surgery. With attention topatient-centred care and a better understanding of theexistence and needs of these three domains of sup-port, clinicians and other decision makers can takeappropriate actions that could potentially improve theoverall patient experience and satisfaction with TKA.Endnotes1Our research team was highly interdisciplinary; assuch our analysis for this paper was informed by personstrained in at least one of the following disciplines: healthservices and policy research, population and publichealth, health economics, psychology, epidemiology, pol-itical science, nursing, and orthopedic surgery.AbbreviationsTKA: Total knee arthroplastyAcknowledgementsWe thank the TKA patients who participated in this research study, andacknowledge the data collection contributions from Faith Furlong, HeidiHoway, Christine Morrison, Valerie Oglov and Christina Parkin. Studyguidance was provided by our collaborators and advisory team members,including Ramin Mehin, Susann Camus, Susan Chunick, Alison Dormuth,Denise Dunton, Vivian Giglio, Charlie Goldsmith, David Nelson, Cindy Roberts,Magdelena Newman, Joan Vyner, Mike Wasdell, Robert Bourne, and manyothers.FundingThe study “Why are so many patients dissatisfied with knee replacementsurgery? Exploring variations of the patient experience” was funded throughsupport from the Canadian Institutes of Health Research Partnerships forHealth System Improvement (CIHR PHSI) operating grant (number 114106),the Michael Smith Foundation for Health Research (MSFHR; number PJ HSP00004(10–1)), and the BC Rural & Remote Health Research Network. Fundingand in-kind support were received from Vancouver Coastal Health Authorityand Fraser Health Authority. Dr. Sawatzky holds a Canada Research Chair(CRC) in Patient-Reported Outcomes from the Government of Canada CRCprogram. Dr. Davis held postdoctoral funding from CIHR and MSFHR duringthis study. Assistance with the pre-funding study design was providedthrough in-kind support from the Fraser Health Authority. Otherwise, nofunder of this study was involved in the design of the study and collection,analysis and interpretation of data and in writing the manuscript.Availability of data and materialsRequest for access to study data should be directed to the correspondingauthor (LJG). This study has approval for secondary data analysis but anyrelease of data to other parties will require a new ethics approval.Authors’ contributionsLJG led and participated in the design, conduct and analysis of this studyand the drafting of this manuscript. NS and ER participated in the design,conduct and analysis of the study and helped draft the manuscript. JS, VM,RS, SH, JD, PM, and SB participated in the design, conduct and analysis ofthe study and revised the manuscript critically for important intellectualGoldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 11 of 13content. SB also led the overall mixed methods study within which thisqualitative study was embedded. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationAll study participants provided written informed consent for the informationcollected to be used for publication where no information that disclosedtheir identity was released or published.Ethics approval and consent to participateEthics approval for this study was obtained from relevant universities andhealth regions: University of British Columbia, reference number H11-02117 ;Simon Fraser University, reference number 2012 s0142; Trinity WesternUniversity 12 F02; Fraser Health Authority 2011–087, Vancouver CoastalHealth Authority V11–02117; Vancouver Island Health Authority C2012–043;Interior Health Authority 2012–13–010–E; and Northern Health AuthorityRRC–2012–0019. All study participants provided written informed consentprior to enrolment in this study.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Faculty of Health Sciences, Simon Fraser University, Blusson Hall 10506, 8888University Drive, Burnaby, BC V5A 1S6, Canada. 2Centre for ClinicalEpidemiology and Evaluation, Vancouver Coastal Health Research Institute,7th floor, 828 West 10th Avenue, Vancouver, BC V5Z 1M9, Canada. 3School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, BC V6T 1Z3, Canada. 4Department of Experimental Medicine,Faculty of Medicine, University of British Columbia, 10th Floor, 2775 LaurelStreet, Vancouver, BC V5Z 1M9, Canada. 5Burnaby Hospital & SurgicalNetwork, Fraser Health, 3935 Kincaid Street, Burnaby, BC V5K 2X6, Canada.6School of Nursing, Trinity Western University, 7600 Glover Road, Langley, BCV2Y 1Y1, Canada. 7Centre for Health Evaluation and Outcome Sciences,Providence Health Care Research Institute, St. Paul’s Hospital, 588-1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 8Department of Evaluationand Research Service, Fraser Health, Suite 400, Central City Tower, 13450 102Avenue, Surrey, BC V3T 0H1, Canada. 9Department of Physical Therapy,Faculty of Medicine, University of British Columbia, 212 Friedman Building,2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada. 10Aging, Mobility, andCognitive Neurosciences Lab, University of British Columbia, DjavadMowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BCV6T 1Z3, Canada. 11Rebalance MD, 104-3551 Blanshard Street, Victoria, BCV8Z 0B9, Canada.Received: 18 August 2016 Accepted: 6 March 2017References1. 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Ethnic and racial factorsinfluencing well-being, perceived pain, and physical function after primarytotal joint arthroplasty. Clin Orthop Relat Res. 2011;469:1838–45.53. Mota REM, Tarricone R, Ciani O, Bridges JFP, Drummond M. Determinants ofdemand for total hip and knee arthroplasty: a systematic literature review.BMC Health Serv Res. 2012;12:225.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Goldsmith et al. BMC Musculoskeletal Disorders  (2017) 18:127 Page 13 of 13


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