The Patient’s View of Success

Commentary We read the study by Entezari et al. with great interest. In this study, patients who underwent treatment for periprosthetic joint infection (PJI) were interviewed in order to characterize their experience, to assess which factors they associated with a successful outcome, and to evaluate how these factors differed from those used in the Musculoskeletal Infection Society (MSIS) outcome-reporting tool (ORT)’s definition for PJI success1. This study caught our attention due to its qualitative approach and incorporation of the patient experience in defining success. Most of us are familiar with quantitative research, in which we generate hypotheses and assess these hypotheses throughstructured methods. We are often less familiar with qualitative research. Qualitative research asks open-ended questions to better understand factors and complexities that may not be addressed with quantitative methods. Qualitative studies can identify themes that are difficult to quantify, which may help to shape quantitative studies. In their study, Entezari et al. chose a phenomenological approach, which is a qualitative method of explaining an event from the perspective of those who experienced it2,3. We must understand why qualitative studies are needed in the context of PJI. It is well established that PJI is a challenging problem, and quantitative studies have evaluated established patient-reported outcome scores, such as the Oxford Hip and Knee Scores, in order to understand clinical outcomes following PJI treatment4,5. However, a clinician telling a patient that they are at risk for a poor clinical outcome if they get a PJI may not help them to understand what is at stake if they get an infection, what emotions they may experience, and what functional limitations they may have. The study by Entezari et al. was able to explore this space—one that is not quantified in our current metrics for success. Specifically, the patients in this study reported sadness, anger, surprise, disappointment, confusion, and feeling overwhelmed at the time of PJI diagnosis. Further, patients struggled with the length of treatment, limited mobility, and short and long-term physical limitations. A key takeaway was that some patients described a lack of understanding of and preparedness for PJI, which contributed to negative feelings such as anger and surprise. This may have also delayed diagnoses, as some patients felt that they did not understand the seriousness of PJI. The authors proposed the use of visual aids, decision aids, and comprehensive counseling to help patients better understand this risk. Patient education is critical and challenging. When clinicians discuss risks with patients, patients may not follow all of the details and may allow emotions rather than facts to affect their understanding and decision-making; therefore, it is important for clinicians to display both competence and compassion in these discussions6. Visual aids can elicit dialogue and understanding and can ultimately deepen the clinician-patient therapeutic relationship6. In consultations or preoperative visits, clinicians, in some cases, may feel that time constraints prevent them from exploring the emotions and understanding of the patient. Perhaps this is an opportunity to schedule a follow-up visit in order to spend additional time on these topics. The study by Entezari et al. also sheds light on how patients perceive successful treatment. Patients agreed with clinicians that infection eradication was of great importance. However, patients also valued function, pain relief, mobility, and independence, which may not be well captured in the current measures that are used to evaluate PJI treatment. This is evident in the finding that one-third of patients disagreed with their MSIS ORT classification, with the patients stating that the classification failed to evaluate for quality of life. This information is important, and the classifications that are used to evaluate successful PJI treatment may benefit from including patient function, pain relief, mobility, and independence. This study is an example of how qualitative research informs quantitative research. The MSIS has discussed that one of the limitations of the ORT is the lack of a validated patient-reported outcome measure (PROM)1. Being infection-free but unable to walk without gait aids, dependent on others, and in pain is likely not a successful outcome from the patient perspective. Future research, as well as the present study, can help to develop and validate a PJI-specific PROM. With such a PROM, we may find that certain surgical treatment options have lower infection eradication rates but higher patient-specific PROM scores. Or perhaps we may better understand the patient experience with this measure and can better inform patients of the risks prior to their index arthroplasty.