Journal of Rehabilitation Medicine 51-10

Preoperative education for hip and knee replacement study included a much smaller number of patients (n = 261 vs 1,233 in the current study) over a similar time period, with a much higher rate of non-participa- tion (36% vs 17.5%). Similarly, in a study on patients undergoing primary and revision knee replacement (11), implementation of an education session led to a reduction in length of stay from 7 days to 5 days (p < 0.01). However, the current study differs in that it evaluates attendees and non-attendees, and is not a before and after comparison. The RAPT questionnaire was originally designed to identify a patient’s risk of needing extended inpatient rehabilitation following total hip or knee replacement (21). Seven risk factors related to discharge were re- cognized as: age, sex, preoperative walking distance, preoperative gait aid, community support, the presence of a caregiver on return home, and patient expectation (21). Patient expectation was found to significantly impact outcome, but was considered unstable due to a range of influences, including patient and caregiver’s perceptions of efficacy, and was therefore removed from the final RAPT model (21). Recommendations were given to discuss patient expectations during pre- admission assessment to help clinicians and patients mutually agree a discharge plan (21). Therefore, it is possible that the significant reduction in length of stay between RAPT- graded high-risk patients who did and did not attend a preoperative education class was due to altered patient expectations. The specific aims of the session were to reduce anxiety and pro- vide a detailed explanation of the pathway to both patients and their carers (23), since procedure-related uncertainty in addition to unrealistic expectations of outcome can contribute to anxiety and negatively af- fect postoperative recovery (28). Anxiety is adaptive in motivating behaviour that helps patients to cope with threatening situations, such as surgery, and, as feelings of control encourage anxiety to become faci- litative, it is important that a patient receives sufficient information in order to improve their coping ability. The amount of information required to be facilitative is patient-dependent (18) and therefore personalizing preoperative education to complement the patient’s RAPT score, or other preoperative risk screening tools, can help to manage patient expectations. Furthermore, adequate screening of physiological and cognitive reserves in patients scheduled for surgery can identify those who are elderly, isolated, or functio- nally impaired preoperatively and enable proactive perioperative management strategies to reduce adverse postoperative outcomes or readmission (29). During the education class, patients were encouraged to discuss any equipment they required for their return home (23). Subsequently, appropriate discharge arrangements 791 could be made preoperatively in order to facilitate the return home. For example, where community support or additional care was lacking, home health services could be arranged. Failure to attend the class may have resulted in the communication of needs occurring post-operatively, which could delay discharge. Given that outpatient or day-case surgery is now possible for hip and knee replacement procedures (30), healthcare professionals may have less time to identify patients who require additional support. Therefore, attendance at a preoperative education class is important to facilitate the management of high-risk patients. The results of the current study demonstrate a sig- nificant reduction in length of stay for high-risk total knee replacement patients who attended their preope- rative education class; however, the effect within the cohort of patients undergoing hip replacement was non-significant. These results are consistent with the wider literature, since, although the 2 procedures are regularly investigated together, they are different pro- cedures and there is a difference in the “success” rate of hip and knee replacements (31). Total hip replace- ment is considered highly successful, with very good long-term results (32); however, there is evidence that reports patient dissatisfaction (33, 34) and a prolonged recovery in the early and intermediate postoperative period following knee replacement surgery (35, 36). Patients have reported feeling “unsafe” undergoing total knee replacement on an outpatient basis (37), and there are differences in the characteristics of the population that develop knee and hip osteoarthritis, which may affect the psychological status of a patient (31). For example, a high body mass index is often correlated with the development and progression of osteoarthritis of the knee, but not of the hip (38), and obesity has been linked to an increased psychological burden (39). Impaired psychological health, uncertain expectations of surgery and fear of the operation are reported to affect decision-making regarding knee replacement (31), and therefore patients on the waiting list may catastrophize or engage in negative health behaviours. Fortunately, negative thoughts are susceptible to change and can be reframed using cognitive-restructuring techniques, and therefore, high-risk patients undergoing knee replacement may have the most to gain from attending a preoperative education class, as suggested by the results of the current study. Adopting a biopsychological model in education, which focuses on the complex interac- tion between psychological, social and biological factors that contribute to health problems can help patients to understand the thoughts and feelings that influence their behaviours (40). Therefore, incor- porating cognitive-behavioural approaches into the J Rehabil Med 51, 2019

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