The hip journey

Hofteskjellet. Illustrasjon.

An exploration of patient needs, treatment decision-making and psychosocial predictors of surgical outcomes in patients with hip osteoarthritis.


Osteoarthritis is a common, but potentially disabling disease

Osteoarthritis (OA) is a degenerative condition leading to reduced joint function. Most people knows a person affected by OA, as it is the most frequent joint-disease in Norway and in other western countries. The number of people affected with symptomatic OA is likely to increase due to the aging of the population and the obesity epidemic. A prevalence survey shows that nearly 13% of Norway's population has osteoarthritis in either hand, knee or hip. This means that approximately 683,000 Norwegian people have been diagnosed and, to a greater or lesser extent, are in need of healthcare, due to limitations in physical function, both in daily life and at work.

Unfortunately, no curative treatment for OA exist today. Each person’s situation require comprehensive assessment and available treatment methods must be adapted individually. According to clinical guidelines, all patients should receive education about OA, increase the activity level through customized exercises, preferably under the guidance of a physiotherapist, lose weight if relevant, and integrate other effective coping strategies in everyday life. Some benefit from pain medication, and in cases where the condition develops further and results in significant consequences for functional ability and quality of life, surgical treatment options may be applicable.

Total hip replacement, which involves the insertion of an artificial hip joint (prosthesis), is an effective form of surgical treatment for patients with severe hip OA. 7050 primary hip replacements were performed in Norway in 2016 under the indication of symptomatic hip OA. Modern surgery techniques contribute to the relatively small risk associated with this type of surgery. However, as it is a comprehensive procedure, it requires the patient to be medically fit and motivated for a demanding rehabilitation period with a risk of potentially serious complications such as persistent pain, deep joint infection, loosening of prosthetic components and luxation.

Patient involvement

As outlined above, the treatment of hip OA requires close collaboration between patient and health professionals in both primary and specialist health services. The patient needs tailored information and guidance at an early stage on how to implement viable self-management strategies and make informed decisions. In this decision-making process, the patient must be given realistic opportunities to contribute as an active participant as 'expert' in his / her own life. This is described as a shared decision-making (SDM), and is by policy makers highlighted as an important step towards the realization of ‘the patient's health service’. Integration of knowledge and patient involvement through SDM is demanded in the National Health and Hospital Plan 2015, Drug Report 2015 and in the Storting Report on Quality and Patient Safety 2015. Despite the increasing attention and focus on SDM, and the obvious moral significance of the factual involvement of the patient in decisions on treatment, research show that there is a gap between theory and practice.

In Norway, national guidelines for prioritizing exist as decision support for referring physicians to specialist health services. Key priority factors include:

  • Extent of pain and functional decline (especially rest and night pain)
  • Lack of effect of conservative treatment
  • Correspondence between clinical and objective findings (conventional x-ray)
  • Extent of limitations in daily living

Most of these are subjective parameters, so it is up to the doctor and the patient to decide together how the condition develops over time and eventually affect the patient's functional ability and quality of life.

The relationship between patients and doctors is often described as asymmetric. Doctors are on home ground. They are trained in clinical reasoning, have accessible decision support systems and evidence-based guidelines. They meet patients every day, and can improve their medical expertise continuously. The patient however, is far from home ground, and it may be his or her first meeting with a doctor. Being dependent on others’ expert opinions and decisions regarding own health is in itself a vulnerable position. One way to level out the asymmetry is to actively recognize the patient’s as a competent part of the relationship, and respond appropriately to hints or cues of concerns. Importantly, the patients holds one vital part of the decision-making puzzle. He or she knows how the hip pain feels and ultimately how it effects daily life.

"Mine Behandlingsvalg" – a decision-aid for patients with hip osteoarthritis

An essential part of this research project is the development of a web-based patient decision aid (PDA). The PDA is developed together with patients, health professionals, researchers and other experts. It provide patients with evidence-based and tailored information (text and videos), and support on how to select the preferred treatment option together with health professionals. It is published as an integrated part of the Norwegian health portal Helsenorge.no (www.helsenorge.no/samvalg) during the autumn of 2018.

Publications:

Brembo, E. A., Kapstad, H., Dulmen, S. V., & Eide, H. (2017). Role of self-efficacy and social support in short-term recovery after total hip replacement: a prospective cohort study. Health and quality of life outcomes, 15(1). doi:10.1186/s12955-017-0649-1.

Brembo, E. A., Kapstad, H., Eide, T., Månsson, L., Van Dulmen, S. & Eide, H. (2016). Patient information and emotional needs across the hip osteoarthritis continuum: a qualitative study. BMC Health Services Research, 16(1), 1-15.

Project members

Collaboration

Vestre Viken HF, Department of Orthopedics and Emergency unit – Vestre Viken Hospital Trust, Drammen hospital

Mine Behandlingsvalg, Northern Norway Regional Health Authority, University Hospital of Northern Norway

A person-centered research project.

In the first study, we individually interviewed 13 patients about their experiences from living with hip OA in daily living, and personal factors that had been important for them when making treatment decisions.

In the second study, we use statistical methods to determine the potential role of social support and self-efficacy in short-term recovery, involving 223 OA patients undergoing total hip replacement.

In the third study (in manuscript), we use observation sessions, audio-recording and thematic analysis to explore how patients with hip OA are involved in decision-making during outpatient consultations, and what elements that either facilitate or impede shared decision-making. Results from paper 3 will inform didactic features of an ongoing development of a patient decision aid (PDA) for treatment of hip OA.

Funding

The University of South-Eastern Norway has funded Espen Andreas Brembo’s PhD.