Incorporating Expected Outcomes into Clinical Decision Making for Total Knee Arthroplasty.

Overview

abstract

OBJECTIVE: Expected outcomes (e.g., expected survivorship after a cancer treatment) have improved decision making around treatment options in many clinical fields. We evaluated the effect of expected values of 3 widely available total knee arthroplasty (TKA) outcomes (risk of serious complications, time to revision, and improvement in pain and function at 2 years after surgery) on clinical recommendation of TKA. METHODS: The RAND/UCLA Appropriateness Criteria (AC) method was utilized to evaluate role of the three expected outcomes clinical recommendation of TKA. The expected outcomes were added to 5 established pre-operative factors from the modified Escobar AC. The 8 indication factors were used to develop 279 clinical scenarios and a panel of 9 clinicians rated the appropriateness of TKA for each scenario as inappropriate, inconclusive, and appropriate. Classification tree analysis was applied to these ratings to identify the most influential of the 8 factors in discriminating TKA appropriateness classifications. RESULTS: Ratings for the 279 appropriateness scenarios deemed 34.4% of scenarios as appropriate, 40.1% as inconclusive, and 25.5% as inappropriate. Classification tree analyses showed that expected improvement in pain and function and expected time to revision were the most influential factors that discriminated among the TKA appropriateness classification categories. CONCLUSION: Our results showed that clinicians would utilize expected post-operative outcomes factors in determining appropriateness for TKA. These results call for further work in this area to incorporate estimates of expected pain/function and revision outcomes into clinical practice to improve decision making for TKA.