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The Journal of Bone and Joint Surgery (American) 86:1366-1374 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.

The Moving Target: A Qualitative Study of Elderly Patients' Decision-Making Regarding Total Joint Replacement Surgery

Jocalyn P. Clark, MSc, PhD1, Pamela L. Hudak, BScPT, PhD2, Gillian A. Hawker, MD, MSc, FRCPC3, Peter C. Coyte, PhD4, Nizar N. Mahomed, MD, ScD, FRCSC5, Hans J. Kreder, MD, MPH, FRCSC6 and James G. Wright, MD, MPH, FRCSC7

1 BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR, United Kingdom
2 Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
3 Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, 76 Grenville Street, 10th Floor, East Room 1010, Toronto, ON M5S 1B6, Canada
4 Graduate Department of Health Policy, Management and Evaluation, McMurrich Building, University of Toronto, Toronto, ON M5S 1A8, Canada
5 Division of Orthopaedics, Toronto Western Hospital, EC 1-002, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
6 Division of Orthopaedic Surgery, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, MG 365, Toronto, ON M4N 3M5, Canada
7 Division of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada. E-mail address: jim.wright{at}sickkids.ca

In support of their research or preparation of this manuscript, one or more of the authors received Grant MT-15469 from the Medical Research Council of Canada and Grant 99/093 (renumbered as 99/0143 in 2001) from the Canadian Arthritis Society. J.P.C. is a doctoral fellow of the Canadian Institutes of Health Research, G.A.H. and J.G.W. are recipients of Canadian Institutes of Health Research (formerly Medical Research Council) Investigator Awards, and J.G.W. is the R.B. Sauter Chair of Surgical Research. Financial support from these sources is acknowledged. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

This work was presented at the Annual Meeting of the Society for Clinical Epidemiology and Health Care Research, San Diego, California, May 11, 2001, and the International Qualitative Health Research Conference, Banff, Alberta, Canada, April 21, 2000.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department at 781-449-9780, to order the CDM-ROM).

Background: Total joint replacement is an accepted, cost-effective, and underutilized treatment for moderate-to-severe hip and knee arthritis. Yet, research has suggested that many patients with arthritis are unwilling to consider total joint replacement surgery. We sought to understand these patients' unwillingness by exploring the nature of their decision-making processes.

Methods: In-depth interviews were conducted with seventeen individuals with moderate-to-severe arthritis who were appropriate candidates for, but unwilling to consider, total joint replacement. The interviews were analyzed with use of qualitative methods and content analysis techniques.

Results: Symptoms and information sources were the two main factors influencing patient decision-making. Participants engaged in individualized processes of trading off perceived costs and benefits. Accommodation to pain and disability and minimization of the quality-of-life benefit, in view of decreasing life span, led to a process whereby the threshold at which the benefits compared with the risks would tilt in favor of total joint replacement was constantly shifting, a phenomenon we called "the moving target."

Conclusions and Clinical Relevance: The moving-target characterization sheds light on patients' conceptions of their arthritis and on their unwillingness to consider total joint replacement. This process needs to be considered when developing ways to aid decision-making.


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