The Development of a Surgical Readiness Interview Tool for Patients to Improve Conversation on Modifiable Risk Factors Prior to Total Joint Arthroplasty

1 Background: Total joint arthroplasty (TJA) surgery is conducted for severe hip and knee 2 osteoarthritis (OA). However, a significant number of patients referred to orthopedic surgeons with 3 hip and knee OA are not appropriate surgical candidates. Further, many are sent back to their 4 primary care physician because they had not yet exhausted non-surgical options, which suggests 5 the importance surgeons place on exhausting conservative management before proceeding with 6 TJA. The objective of this qualitative inquiry was to 1) explore patients’ perspectives of a surgical 7 readiness interview tool and its potential utility in the management process for patients with OA, 8 and 2) gain input from study participants to further refine the tool and ensure that it is reflective of 9 the patients’ needs and perspectives. 10 Methods: We used a diverse convenience sampling strategy to recruit TJA patients from the hip 11 and knee arthroplasty clinics in Calgary, Alberta. Semi-structured qualitative interviews were 12 conducted using a cognitive interviewing approach in order to elicit information regarding clarity 13 and relevance of the interview tool. All interviews were digitally recorded and transcribed 14 verbatim. Through an iterative process, a coding framework was developed and then applied in 15 the analysis of all interviews. 16 Results: Nine interviews were conducted (n=3 males and n=6), all of whom had a TJA within the 17 previous 12 months. Participants found the questions in the interview tool to be clear and relevant, 18 and nothing listed was unexpected. All participants expressed that they felt comfortable discussing 19 the content of the interview tool with their doctors. The main themes that emerged from the 20 interviews include 1) the need for clarifications, 2) patient-oriented changes, and 3) expectation 21 management. While gaining insight from study participants, the qualitative inquiry confirmed utility of the tool improve the conversation about surgical readiness and utilizing conservative 23 management prior to TJA. 24 Conclusions: Overall, participants were positive about the interview tool and felt that it would 25 lead to better care provision. We recommend the use of the interview tool in primary care settings 26 to support the conversation on modifiable risk factors and non-surgical management strategies for 27 OA prior to TJA. 28

Readiness Interview Tool for Joint Arthroplasty 6

Development of the Interview Tool 77
The Surgical Readiness Interview Tool (Table 1) was developed by assessing the current evidence-78 based guidelines and recommendations for both TJA and optimizing surgical outcomes. 79 Specifically, the interview tool aims to improve the conversation regarding modifiable risk factors 80 that contribute to adverse surgical outcomes in TJA and provide guidance for appropriate referrals 81 to the orthopedic surgeon. The language used is based on current motivational interviewing (MI) 82 techniques and used to identify patient knowledge, engagement, and ability to change (15). MI 83 also enhances patient locus of control and encourages a collaborative patient-physician 84 partnership. By utilizing these techniques, the tool is meant to empower the patient and encourage 85 them to play an active role in their health care decisions. In keeping with the patient-centered 86 approach, the student team felt it necessary to include multiple risk factors. Further, weight loss is 87 a particularly sensitive topic, and often the focus of such conversations. Yet, weight loss is not 88 consistently supported in the literature to enhance TJA outcomes (15) and the student team was 89 unable to develop an equitable and non-stigmatizing strategy to triage patients with and without 90 obesity issues. In the instances where the interview tool does ask the patient to self-report on 91 weight or weight related subjects, we have utilized weight-related language that is safe and non-92 stigmatizing (15). In addition, the interview tool also includes evidence-based non-surgical 93 management strategies to ensure patients are aware of and have exhausted all other treatment 94 options prior to consult for surgery. 95

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The interview tool has been presented to clinicians and clinical support staff of arthroplasty clinics 97 from across Alberta at BJH SCN provincial meetings (a multidisciplinary BJH SCN Core 98 Committee meeting and a BJH SCN workshop focused on care for individuals living with OA and 99 Readiness Interview Tool for Joint Arthroplasty 7 obesity (16). Feedback was generally positive and included specific recommendations on how the 100 tool could be further refined and context for uptake and integration in the OA care and referral 101 processes. Although there was interest from some clinics to test the tool in their settings, it was 102 recognition that a key stakeholder in the uptake and utility of this tool are patients. Hence, the team 103 determined to obtain input from patients to confirm utility and alignment with patient needs. 104 Further, with patient input, there was need to determine the optimal operational placement of the 105 toolin primary care settings or central intake hip and knee clinics. The primary objective of the 106 qualitative inquiry reported on here was to explore patients' perspectives with the interview tool 107 and its potential utility in the management process for patients with OA, with the goal of improving 108 conversation in regard to managing modifiable risk factors that contribute to adverse surgical 109 outcomes in TJA and surgical readiness. The secondary objective was to gain input from study 110 participants to further refine the tool and ensure that it is reflective of the patients' needs and 111 To address our research questions, we conducted interviews with a diverse sample of patients who 127 had previously undergone at least one TJA at one of the recruitment sites. A convenience sampling 128 strategy was used and with the aim of including a range of participants (male/female; broad age 129 range; no requirements related to education, residence location or other underlying conditions). 130 The final sample was determined by the diversity criterion and data saturationrecruitment was 131 stopped when the team determined that no new codes or categories were emerging with additional 132 interviews. Participants were recruited from the hip and knee arthroplasty clinics in Calgary. 133 Potential participants were approached about the study by clinic managers during their routine 134 post-TJA follow up appointment. If consent to be contacted by one of the research team members 135 was obtained, contact for the interviews was initiated by the research/student team, with consent 136 obtained prior to the interview. 137 138

Data Collection 139
Semi-structured qualitative interviews were conducted by telephone by KIB, NLT and CEH. The 140 interviews applied a cognitive interviewing approach in order to elicit information regarding 141 clarity of questions and response options, and relevance of topics covered in the tool. Drawing on 142 the experience of the participants, we also wanted to determine if any topics related to surgical 143 readiness and/or modifiable factors were missing in the tool. Based on a preliminary analysis of 144 the first 2 interviews, AKR provided minor revisions to the interview guide and additional coaching on how to frame questions in a semi-structured format during the interview process. All 146 interviews were digitally recorded and transcribed verbatim. 147 148

Data Analysis 149
The analysis, led by AKR, was initiated after the first 3 interviews were completed. The first step 150 involved listening to all recordings for initial emersion into the data. Each transcript was then 151 analyzed by two of the team members (AKR, KIB). Codes and categories identified by each 152 member were compared to determine corroboration through three rounds. Any discrepancies were 153 further discussed and final decisions regarding codes/categories were consensus based. Through 154 several iterations, codes and categories were identified, resulting in the development of an 155 emergent coding framework. The coding framework was then applied to all interviews and based 156 on similarities, patterns, and relationships between categories, emergent themes were identified. 157

159
Participants 160 The participant sample (n=9), included males (n=3) and females (n=6), and, at the time of the 161 interview, all had a TJA within the previous 12 months. One participant had more than one TJA. The coding framework, which outlines the codes and categories identified during the analysis 182 process are outlined in Table 3. Through the analytic process, three themes emergedneed for 183 clarifications, patient oriented changes, and expectation managementwhich are described below. 184 185

Need for Clarification 186
The key areas that raised questions for participant were related to tool administration, question 187 priority, and relative importance of the topics in relation to determining readiness for surgery. A 188 few of the participants were unclear about the method of administration -whether it would be done 189 by the patient alone or with a doctor, or by the doctor. Timing of administration, in relation to a 190 referral or scheduling of a surgery, was also raised by a few participants. This was important as it 191 Readiness Interview Tool for Joint Arthroplasty 11 appeared to determine the purpose of the tool: later administration seemed to mean it would be 192 used as a decision making tool for the doctor regarding referral to a specialist for surgery whereas 193 earlier administration meant it functioned more as tool for the patient to help assess what needed 194 to be done to enhance their surgical readiness. There was some preference towards earlier 195 administration and using the tool as a readiness tool for the patient. 196

197
There was some question as to whether the order of questions reflected a priority in relation to 198 surgical readiness, which suggested that the first topics were more important than those listed 199 towards the end. Related to this, some participants were unclear about the relative importance of 200 the questions. For example, almost all agreed that exercise and physical strength were important, 201 however, questions were raised regarding the relevance of the weight question. This was due to 202 the inconsistency observed, as discussed by several participants, regarding excess weight and its 203 impact on surgery and/or surgical outcomes. For example, several participants observed that some 204 people who were over-weight had surgery "…and did just fine". Some who were not over-weight 205 had poor outcomes. Therefore, focus on or any emphasis on weight seemed contradictory or 206 confusing to participants. 207 208

Patient Oriented Changes 209
Several changes to the language and content were proposed by participants to further enhance the 210 tool. In terms of terminology used in the questions, asking about a patient's confidence in relation 211 to their readiness did not "resonate" for one participant as they did not think this was an issue of 212 confidence. For the few participants who were dissatisfied with the question specific to weight 213 management, the issue appeared to hinge on how the question was stated. The way the question was worded seemed to imply that weight was a concern or an issue, which "automatically makes 215 one defensive …" (Participant 3). Similarly, use of "excess weight" was interpreted as an 216 assumption that there was a problem with weight. Whereas stating "weight' or 'weight 217 management' in the question was perceived to be more neutral, asking it a question about weight 218 instead of a weight issue. Most participants shared the opinion that the use of "excess weight" was 219 preferable to "over-weight" or "obese" or "fat" as these appeared be interpreted as an insult or 220 negative judgement of the person. The sensitized meaning of these words appeared to be important 221 to participants, as reflected in the experience of Participant 8:

I remember he was just so deflated. And he just felt like, he didn't know what the next step 279
was" (Participant 2). 280 Some also spoke of a 'vicious cycle' that doctors appeared unaware of, and, in some ways, was 282 perpetuated by doctors. For instance, one became overweight because they were unable to exercise 283 due to the arthritis and the pain. And now they were expected to lose weight that they gained 284 because they are unable to function and did not have surgery that they perceived would give them 285 the function back. This is captured in the experience of Participant 3: 286 Lastly, there is an expectation that people will respond to the questions in the tool honestly. 292 However, one participant pointed out that if the tool is used to inform a decision about surgery or 293 referral to a surgeon, this may influence how the patient responds to the question; they may aim to 294 provide the "right answer" instead of an honest answer to get the end result they want -the surgical 295 referral and/or the surgery. 296 297 Based on these findings, the interview tool was revise, incorporating content and wording 298 suggestions from participants. The suggested changes have been incorporated into the readiness 299 interview tool and are presented in Table 2. 300 301 DISCUSSION 302 The present study explored patients' perspectives and experiences with the developed readiness 303 interview tool for TJA. Participants were very positive about the interview tool and felt that it 304 Readiness Interview Tool for Joint Arthroplasty 16 would lead to better care provision. Participants noted that the outlined questions were clear and 305 relevant, and nothing listed was unexpected. All participants expressed that they felt comfortable 306 discussing the content of the interview tool with their doctors. The main themes that emerged from 307 the interviews include the need for clarifications, patient-oriented changes, and expectation 308 management. While gaining insight from study participants, the qualitative inquiry confirmed 309 utility of the tool improve the conversation in regard to modifiable risk factors that contribute to 310 adverse surgical outcomes in TJA and potentially improving appropriate surgical referrals. 311 312 A perspective identified across multiple interviews was that the tool was medicine or physician 313 centric. Study participants recognized that the interview tool was a useful educational and 314 awareness tool of non-operative options prior to the TJA referral to an orthopedic surgeonfor 315 themselves and their doctors. However, it was perceived as primarily oriented towards information 316 needs and issues of importance to physicians and not necessarily the patient. The goal of 317 developing this interview tool was to involve the patient and encourage an open dialogue, therefore 318 focusing on a patient centric careto align decisions with patient's needs, wants, and preferences 319 (18-20). To ensure that the tool also meaningful to patients in the context of the OA that they live 320 with and decision-making regarding surgery and surgical readiness, input from study participants 321 was incorporated in the interview tool. 322 323 An important topic that emerged during the interviews was around the intention of the response to 324 the questions. There is often an inherent assumption, if not expectation, that patients respond to 325 questionnaires or questions in the context of a consultation with a physician in an honest or 326 transparent manner. However, several participants endorsed the notion that some may answer the questions on how the physician would want the answers to be completed with the goal of getting 328 TJA, and not necessarily honestly; therefore, not optimizing all non-operative options prior to TJA, 329 as TJA was viewed as the solution compared to weight loss, diabetes control, etc. Interview 330 respondents also noted that potentially patients "would say what they needed to" to get a referral 331 to an orthopaedic surgeon. A similar issue was addressed in a study by Burt et al (2017) exploring 332 how patients' choices of response options related the nature of the primary care physician 333 consultation. The authors concluded that drivers impacting responses to questionnaires include the 334 nature of the consultation with a primary care physician and expectations of that consultation, and 335 the power differential between a doctor and the patient (17). This highlights the need for careful 336 consideration of when the interview is administered in the process of OA management as this may 337 potentially influence how a patient responds to the tool items. 338 339 A framework for an evidence-based, multidisciplinary, patient-centered, approach to hip or knee 340 OA has been developed (21). The stepped care approach provides a progressive strategy to 341 management and treatment of OA that is initiated with low intensity evidence-informed 342 interventions with an emphasis on self-management in step 1. This is progressed to increasingly 343 more intensive treatment interventions with step 2 including exercise therapy, dietary therapy, and 344 non-steroidal anti-inflammatory drugs, and step 3) treatment options comprising of 345 multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation 346 for patients with persisting complaints (21). Surgery would be the last option, after step 3 347 essentially failed in effective treatment of OA symptoms. With the stepped care approach, it is 348 imperative to both the patient and the health care system to complete the adequate steps in an 349 ordered manner, and the steps should need to be done prior to invasive therapy. Further, to provide value, a stepped care strategy needs to be consistent within primary care, as there are effects on 351 costs and long-term effects (22). In a previous study that evaluated the extent to which clinical 352 practice was consistent with the stepped care strategy in hip or knee OA, consistency was found 353 in about half of the patients within the aspects of care (consistency regarding timing of radiological 354 assessment, sequence of non-surgical treatment options, and making follow-up appointments) 355 (23). The inconsistencies mainly focused around underuse of lifestyle advice and dietary therapy. 356 Further, they found that in 57% of the consultations with their primary care physician, the patient 357 reported to have been advised to make a follow-up appointment (23). Such an approach has taken 358 up by the BJH SCN, as reflected in the BJH SCN's framework for OA management (24). The 359 interview tool may effectively enable the implementation of a stepped care approach in OA care. 360 It could provide consistency within primary care as to what conversations to have prior to any 361 referrals, including consultation for arthroplasty, and then prompt the physician to encourage 362 follow up appointments for both discussion and reassessment of modifiable risk factors. 363 364

Delivery of Tool 365
The interview tool provides a unique opportunity to allow the patient to play an active role in their 366 care. This interview tool provides a valuable opportunity for the physician to have a conversation 367 and educate their patients about different modifiable risk factors. Also, it can be used to guide the 368 patient to local resources (i.e. physiotherapists, kinesiologists, dieticians, diabetes management 369 clinics, smoking cessation clinics, etc.) available to help address these risk factors. This open 370 dialogue will help identify which risk factors the patient is willing and able to start making changes 371 on. We encourage the primary care physicians to follow the patient serially throughout this process 372 and therefore aiming to decrease their overall health risk prior to consultation to the surgeon, if there is sufficient need to proceed to TJA. Further, the interview tool could assist in effectively 374 managing expectations. Ideally, the interview tool would be an included in the referral 375 documentation for TJA. Its uptake could result in improvements in referral efficiency by 376 appropriately triaging poor current surgical candidates to other health care professionals prior to 377 orthopaedic surgeons, that would in turn reduce inappropriate surgeon referrals, improve patient 378 monitoring in primary care, decrease wait times, and possibly delay the need for TJA. 379 380 This study is not without limitations. First, the patients were recruited from the hip and knee 381 arthroplasty clinics in Calgary, Alberta. Although we aimed for diversity in our sample, this is an 382 inherently limited sample given the geographic location of the recruitment sites. Second, the 383 patients were identified from the clinic managers and then invited to participate, therefore 384 introducing potential selection bias into which patients were invited to be interviewed. The 385 cognitive interviewing approach was relatively new to the interviewers. This led to some 386 inconsistency in how the interviews were conducted by the three interviewers. However, the semi-387 structured approach allows for flexibility in the flow of an interview to ensure research objectives 388 are addressed. Further, almost all interviews (6/9) were conducted by the same interviewer (KB). 389 390

Future Directions 391
Dissemination of the revised interview tool in Alberta to BJH SCN stakeholders will be continued 392 in order to identify optimal operational uptake within the primary care setting and/or OA tool kits 393 currently in development by the BJH SCN to enhance OA care across the continuum and in context 394 of the patient's lived OA journey. These processes continue to be supported by the BJH SCN and 395 uptake is dependent on interested local primary care clinics and sites in Alberta. Once an uptake site is identified, a critical next step will be to test the interview tool in the clinic setting and its 397 impact on patient outcomes and care processes. 398 399 CONCLUSIONS 400 In summary, this study demonstrated that participants were positive about the proposed interview 401 tool. Findings confirmed utility of the interview tool to improve the conversation on surgical 402 readiness and specifically modifiable risk factors that contribute to adverse surgical outcomes in 403 TJA. Participants believed these discussions would lead to better care provision. The provision of 404 a tool that asks patients to rate their understanding of their surgical risk factors, the importance of 405 modifying those risk factors, and their confidence in being able to modify same will likely 406 encourage patient-directed strategies and care, and reduce the number of inappropriate consults 407 seen by orthopedic surgeons.

Ethics approval and consent to participate 416
Ethics approval was received from the Conjoint Research Ethics Board at the University of 417 Calgary (Ethics ID: REB17-1814). All participants completed informed consent prior to the study. 418 Table 1 The readiness interview tool for patients to improve conversation on modifiable risk 520 factors prior to total joint arthroplasty (TJA). The revised suggested changes are in grey text. 521 522 Table 2 Suggested changes for the readiness interview tool from study participants. 523 524 Table 3 Coding framework. 525