This study specifically aimed to explore the patient experience of ERAS-outpatient programs compared to STD-inpatient programs and to identify elements that could optimize patients’ experience. It also sought to determine whether and how patient characteristics, clinical outcomes and satisfaction of care components are associated with patients’ experience. The qualitative analysis demonstrated that the quality of support received by the patients throughout the episode of care is important to their TJA experience, and that overall, patients had a better experience with the ERAS-outpatient program because they felt better supported by staff dedicated to ambulatory surgery in the ward, they experienced less postoperative inconvenience, went home sooner and recovered more quickly. Furthermore, patients suggested that their TJA experience could possibly be enhanced by improving the information given in the preparation phase, providing more postoperative physiotherapy sessions at home if needed and ensuring better coherence of care between orthopaedic and homecare teams. The bivariate analyzes revealed no statistically significant relationship between patient experience and patient characteristics or clinical outcomes and weak to moderate positive correlations between patient experience and satisfaction with pain management, hospital stay, postoperative recovery, homecare and overall results. Taken separately, these findings enhance our comprehension of the patient TJA experience. Nevertheless, this study’s overarching objective was to gain a more in-depth understanding of the patient experience for both STD-inpatient and ERAS-outpatient total joint arthroplasty by combining the strengths of quantitative and qualitative approaches.19 Consequently, qualitative and quantitative results were integrated together and compared to the literature in the following paragraphs.
Some studies on TJA found that age and certain comorbidities are predictors of postoperative satisfaction which could have altered patient experience.22,23,24,25 Nevertheless, the impact of these patient characteristics is still controversial as many other studies on TJA, on the other hand, found no significant correlations.15,26,27,28 Our findings corroborated the latter as the bivariate analyses did not find any significant correlation between patient experience and patient characteristics. Moreover, in the qualitative phase, participants did not mention how their age or their comorbidities affected their experience throughout the episode of care. When taken together, these findings suggest that patients’ characteristics are not associated with patient experience and that the enhanced patient experience in the ERAS-outpatient programs was unlikely to be associated with the difference in patients’ age and comorbidities between surgeries.
In this cohort of patients, it was shown that compared to the STD-inpatient care, the ERAS-outpatient program resulted in fewer complications, similar postoperative pain with less opioid consumption and sooner functional recovery.12 These findings were corroborated by the present qualitative analysis and are also in line with the conclusion of many studies that showed that prevention of complications,23,28,29 well-relieved pain27,28,29 and rapid recovery28,29,30,31 after TJA are predictors of better patient satisfaction. However, we did not find any significant correlation between these clinical outcomes and the patient experience nor did other studies.32,33 These divergent results may be explained by the fact that strengths of relationship with patient experience after TJA are shaped by the focus of the question.25 Our question referred specifically to the patients’ overall care experience, a complex concept which differs from the overall satisfaction evaluated in the other studies.23,27,28,29,30,31,34 Also, the different quantitative and qualitative findings underscored the importance of going beyond quantitative assessment alone to truly understand what influences patients’ TJA experience. Patients clearly discussed how clinical outcomes, such as adverse events, pain, and functional recovery, affected their experience, although no correlation was found.35
Sooner and better recovery after surgery is the main goal of ERAS interventions and represented some of the main reasons why patients reported a better TJA experience with the ERAS-outpatient program.36 Indeed, satisfaction with postoperative recovery was positively associated with patient overall experience of care. Patients appreciated that the epidural-sedation combination had the advantage over spinal anesthesia alone of eliminating the distress associated with being awake during the operation and that it made them feel better and recover more quickly after surgery.37,38 The ERAS-outpatient rehabilitation protocol was even perceived as “enhanced and better adapted”, although the only difference with the STD-inpatient program was earlier postoperative evaluation and ambulation. Still, earlier ambulation after TJA was shown to reduce complications and to improve pain, muscles strength, range of motion, gait and overall function in the post-acute phase which may explain why patients enjoyed their recovery more following the ERAS-outpatient surgery.39,40,41,42 The rapid mobilization after surgery in the ERAS-outpatient program also contributed to a reduction in the number of rehabilitation sessions needed to reach full functional autonomy which was greatly appreciated by the patients.12,39 Thus, by improving the recovery process, the ERAS-outpatient program enhanced the patients’ overall TJA experience. Similarly, Johansson Stark et al.43 observed that a positive patient experience increased the likelihood of better postoperative recovery. Consequently, as recommended by Doyle et al.14, all three pillars of quality of care (patient safety, clinical effectiveness and patient experience) should be viewed as a group and interventions should aim to improve all three to provide high-quality care in TJA programs.
Pain management is crucial after TJA, as unrelieved pain can negatively affect recovery and patient experience.44,45,46,47,48 Indeed, satisfaction with pain management was found to be weakly to fairly positively correlated with patient experience. Rapid and effective pain relief is even more important in outpatient programs as it is a major reason for failure to discharge within the expected time frame.49 With outpatient programs, patients become quickly responsible for their pain management and it was shown to often result in unrelieved pain.45,50 When self-medicating, patients are often reluctant to take the prescribed analgesics because they are not sure when to take them or because they are afraid of developing an addiction.45,46,50 Despite these additional challenges, our participants preferred the ERAS-outpatient pain management protocol that combined preemptive medication, dexamethasone, epidural-sedation anesthesia, local infiltration analgesia and multimodal analgesics over the STD-inpatient modalities that often included narcotics, because they felt it was more effective and they had less concern about developing a dependency. The patients also enjoyed being able to quickly self-manage their analgesics consumption in the post-acute phase with the ERAS-outpatient program because it enabled them to alleviate their pain rapidly, without having to wait for nursing staff. This was shown to be strongly associated with better overall pain relief and lower need for additional analgesia.51 Compared to other studies’ findings,45,46,50 the superior coping abilities with self-pain management in our study could be due to the extensive education provided to patients in the preparation phase and before discharge, as it enabled them to be knowledgeable and confident with the postoperative process.52 Furthermore, as has been suggested by the patients, the overall care experience would surely benefit from former patients sharing their advice and providing additional information. This would empower patients regarding the process of care, thus increasing their confidence in performing perioperative tasks, such as pain management, and improving their recovery.53,54,55
Hospital Stay and Homecare
Satisfaction with hospital stay and homecare were also found to be fairly to moderately positively correlated with patient experience, which is consistent with patients highlighting the quality of care they received at the hospital and at home as important to their experience. Indeed, patients enjoyed their hospital experience in ERAS-outpatient program more mainly because they felt better supported by nurses and physiotherapists who were specialized in outpatient programs.45 The support at home was also crucial to the patient experience and most patients expressed a positive homecare experience in both programs because they perceived homecare providers as competent, engaged and interested in helping them recover. Still, a few patients were disappointed by the homecare provided, which they deemed unprofessional or not cohesive with the instructions given by the orthopaedic team, thus leading to uncertainty.45 Fortunately, patients benefited from having a caregiver at home in the early postoperative days, which was mandatory to undergo the ERAS-outpatient program, to alleviate the uncertainties of homecare and temper the additional concerns of returning home quickly.56,46 Patients also appreciated that, in both programs, a nurse from the orthopedic team was available by phone to answer uncertainties, ease concerns, and provide information which helped to improve the overall provider-patient relationship.57,58 The present findings reinforced those of McMurray et al.58 stating that relationships between patients and care providers are a key component of the patient experience and that aspects such as caring, empathy, respect and perceived provider expertise all influenced the overall experience.58 On the other hand, the poor homecare experience of some patients underscores the importance of improving and standardizing the quality of home care and educating homecare providers on the rehabilitation protocol, in order to provide a consistent message that will improve patient experience and also potentially improve the postoperative outcome.59
Wound care is also a potential significant contributor to the patient experience in both the early and late postoperative phases, as the scar remains a visible reminder of their journey.60 In this study, we found that satisfaction with wound care was moderately positively associated with patient experience for the ERAS-outpatient surgery but not for the STD-inpatient program. This finding is probably secondary to the distinct interactions of each program that generated a different perception by the patients of the importance of wound care in their care experience.
Still, patients expressed how the combination of subcuticular sutures and tissue adhesive of the ERAS-outpatient program allowed them to shower sooner, avoid the inconvenience of staples (removal and wound discharge) and have better cosmetic results, enhanced their experience.61,62,63 Therefore, optimizing wound care should be considered important to the patients’ TJA experience, especially in outpatient program, where minimizing postoperative inconvenience is crucial to prevent additional concerns and additional episodes of care, which could negate some benefits of outpatient procedures.
Black et al.64 observed a weak positive correlation between patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) at 6 months after a TJA. Similarly, we found that satisfaction with overall results at the last follow-up was fairly to moderately positively correlated with patient experience. However, patients did not express a difference between their ERAS-outpatient and STD-inpatient surgery overall results, which is in line with the similar PROMs at the last follow-up.12 Thus, although there is a positive correlation between patient experience and satisfaction with TJA overall results, it is unlikely that it contributed much to the better overall patient experience found with the ERAS-outpatient program.
The present results must be interpreted taking into consideration this study’s limitations. First, while bivariate analyses quantify the strengths of the relationship between two variables, they do not provide information regarding causality or direction. Nevertheless, this limitation was mostly overcome by the mixed methods design which enable to obtain a complete understanding of the patient experience and its associated factors by integrating qualitative data to the quantitative data. Second, unlike the case with interviews, our survey-based instrument did not allow us to ask sub-questions that may have allowed to further deepen the participants’ points of view. However, the large sample size by qualitative research standards was more than sufficient to gather a great variety of perspectives and experiences. Third, all surgeries were performed in the same Canadian tertiary centre and the results may not be generalizable to other settings. Fourth, all STD-inpatient surgeries were performed before the ERAS-outpatient ones. Nevertheless, the comparison of patient satisfaction between the first and the second procedure in bilateral asynchronous TKA showed no difference.65 Fifth, participants had to recall their surgeries to answer the Patient Experience questionnaire. Yet, many strategies were put in place to minimize the impact of patient recall: participants were their own comparison, they were blind to the study hypothesis, they could take as much time as they needed to answer, data collection was standardized and done simultaneously for both programs.66