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. 2023 Mar 29;76(3):269–281. doi: 10.3138/ptc-2022-0028

Hip and Knee Total Joint Arthroplasty Online Resources for Patients and Health Care Professionals: A Canadian Environmental Scan

Lissa Pacheco-Brousseau *, Stéphane Poitras *, Sarah Ben Amor †, François Desmeules ‡,§, Alda Kiss ‡, Dawn Stacey ‡,**,✉
PMCID: PMC12392839  PMID: 40959155

Abstract

Purpose:

To appraise the quality of publicly available online Canadian resources for patients with hip or knee osteoarthritis considering total joint arthroplasty (TJA) and health care professionals participating in TJA decision-making processes.

Method:

An environmental scan. Two independent authors appraised: a) patient resources against the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Material Evaluation Tool (PEMAT); and b) health care professional resources against six appropriateness criteria for TJA and eight elements of shared decision-making. Analysis was descriptive.

Results:

Of 84 included resources, 71 were for patients, 11 for health care professionals, and 2 for both. For patient resources, the median number of IPDAS defining criteria met was 2 of 7, median PEMAT understandability score was 83%, and median PEMAT actionability score was 60%. For health care professional resources, the median number of appropriateness criteria was 3 of 6, and the median number of shared decision-making elements was 3 of 8.

Conclusions:

Only four of 73 patient resources were structured to help patients consider their options and reach a decision based on their preferences. Health care professional resources were limited to traditional criteria for determining TJA appropriateness (evidence of osteoarthritis, use of conservative treatments) and poorly met key elements of shared decision-making.

Key Words: patient decision aids, patient education, shared decision-making, total hip arthroplasty, total knee arthroplasty.

Hip and knee total joint arthroplasty (TJA) is a frequently performed elective surgery in Canada with numbers steadily increasing each year.1 This upward trend is concerning as Canadian health care services, including TJA, are publicly funded. Although TJA has been demonstrated as generally effective to manage hip and knee osteoarthritis (OA) symptoms and improve quality of life, not all patients benefit from these surgeries. Many experience postoperative pain2 and report dissatisfaction with surgery results.3 The need to receive more information on TJA (e.g., procedure, outcomes, rehabilitation) and other available treatments during the decision-making process has been highlighted by patients to allow them to make a better-informed decision and to promote more realistic expectations.4, 5, 6 This is especially important as most patients want to participate in the decision-making process7 and frequently search the Internet for easily accessible health care information.8

Health care professionals, such as physiotherapists, play an important role in the TJA decision-making process by assessing patient appropriateness for surgery and by helping patients reach an informed decision. However, assessment of patient appropriateness for TJA is still mostly based on clinical criteria such as radiographic evidence of OA with less consideration of patient perspectives (e.g., impact of OA on quality of life and patient readiness).8–10 Consideration of patients’ informed preferences is challenging for many health care professionals.11,12 Most decisions to proceed with elective TJA are based on surgeons’ judgment without considering patients’ informed preferences, and there is poor association between patients’ informed preference for TJA and surgeons’ judgment.4,13,14 This unilateral decision-making process combined with lack of patient information results in approximately 25% to 45% of TJA being of questionable appropriateness.10,15, 16, 17

Effective interventions to ensure patient involvement in decision-making are shared decision-making (SDM) and patient decision aids.18 SDM is an approach whereby patients and health care professionals make health care decisions together by exchanging evidence-based knowledge about harms and benefits of treatment options in order for patients to reach an informed healthcare decision that is congruent with their values and preferences.19,20 Patient decision aids are booklets, videos, or interactive online tools that provide information on available treatment options, benefits, and harms, and also help patients clarify their values for different outcomes of options.18 Patient decision aids are shown to increase patient knowledge, promote realistic expectations, decrease decision conflict, and increase participation in the decision-making process.18 When used in elective TJA decision-making processes, they result in higher-quality decisions and an improved decision-making process.21 The Canadian consensus on appropriateness criteria for TJA supports the shift from traditional criteria such as pain and radiographic evidence of OA to emphasizing patients’ perspective in decision-making by including two SDM criteria (patient has achievable expectations, patient and health care professional agree that potential benefits outweigh potential risks of surgery)18,22 and supporting patient-centred care.22

Despite hip and knee TJA being frequently performed surgeries in Canada, little is known about the available online Canadian resources supporting patients and health care professionals in TJA decision-making processes. The aim of this study is to appraise the quality of publicly available online Canadian resources on TJA for patients with hip or knee OA and health care professionals participating in TJA decision-making processes.

Methods

Design

We conducted an environmental scan to provide evidence on current Canadian practices by gathering and interpreting information.23 It was also used to identify practice gaps and opportunities for improvement.24

Eligible resources

Eligible resources for patients were included if they met the following criteria: a) providing any education and information on TJA for hip or knee OA; b) targeting patients; and c) being publicly available on a Canadian Web site. Patient educational resources including information only on OA and not TJA were excluded.

Eligible resources for health care professionals were included if they met the following criteria: a) supporting health care professionals in determining appropriateness of TJA for patients with hip or knee OA; b) targeting health care professionals; c) being publicly available on a Canadian Web site. Health care professional resources were excluded if they included information only on OA and not TJA, or if they were focused on organization of care or outcomes.

Data sources and search strategy

The search focused on Canadian Web sites to provide a picture of current online resources publicly available to Canadian patients and health care professionals. We searched for TJA resources for patients and health care professionals in all 13 Canadian provincial and territory governmental health care Web sites. Canadian health care associations relevant to OA and TJA were also searched if referenced in a province or territory Web site.

The search was conducted in English, except in Québec where it was conducted in French, by one author (LPB) between May and June 2021 as follows:25–27 1) provincial/territorial health care government Web sites were identified from federal government Web sites and the federal government listing;28 2) each Web site was searched to identify resources related to hip and knee TJA; 3) key words related to TJA were used in Web site search engines if present (e.g., hip/knee/joint replacement AND (education OR decision OR decision aid OR decision support OR process OR pathway OR services OR program)); and 4) key words related to TJA were used in the Google search engine (province/territory name AND same key words as in step 3. If a province/territory government Web site referenced a Canadian health care association, it was searched using steps 2 and 3. Search engine results (Google and Web sites) were limited to the first fifty results or when all results of the next page were irrelevant. Google search engine cache was cleared between searches.26,29,30

Data collection

One author collected data into a data extraction form piloted with one province/territory. The following were collected: a) resource name; b) targeted joint (hip, knee); c) type (e.g., decision aid, written education, video education, referral form, quality of care (e.g., guidelines for appropriate management of OA with TJA)); d) general description of included information; e) URL; f) key word used to identify resources (if any); g) pathway to the resources; h) province/territory/association; i) comments; j) date last updated; and k) date accessed.

Quality appraisal

Two authors (LPB, AK) conducted quality appraisal of patient educational resources and health care professional decision support resources independently. They compared quality appraisal results and differences were discussed until consensus or by consulting a third senior author (DS).

Patient resources

To determine if patient educational resources were decision aids, they were rated against the six defining criteria of the International Patient Decision Aids Standards (IPDAS): a) describes the health condition; b) explicitly states the decision to be considered; c) describes all options available; d) describes the positive features (benefits) of each option; e) describes the negative features (harms) of each option; f) helps clarify values for outcomes of options (e.g., describes what it is like to experience the options). A seventh recently proposed criterion was added: identifies the target population.31,32 When a patient decision aid was identified (meeting all seven defining criteria), six IPDAS certifying criteria were used to evaluate harmful decision bias (e.g., the decision aid shows the negative and positive features of the options with equal detail, the decision aid compares probabilities of options using the same denominator) and 23 quality criteria were used to evaluate the desirable quality characteristics (e.g., the decision aid describes what happens in the natural course of the condition if no action is taken, the decision aid compares probabilities of outcomes of option over the same period of time).31 IPDAS certifying and quality criteria specific to diagnostic testing or screening were excluded.

We assessed the health literacy of patient educational resources using the valid and reliable Patient Education Material Evaluation Tool for Printable Materials (PEMAT-P) or Audiovisual Materials (PEMAT-A/V).33,34 This tool has been demonstrated to have face, content, and construct validity while being internally and externally consistent (interrater reliability).33,34 A strength of the PEMAT is that it offers an audiovisual version and actionability elements.33 This tool assesses the health literacy over two domains: 1) understandability, defined as the ability of consumers of diverse backgrounds and levels of health literacy to process and explain key messages; and 2) actionability, defined as the ability to identify what consumers can do based on the information presented. PEMAT-P includes a total of 17 understandability and seven actionability items, while PEMAT-AV includes a total of 13 understandability and four actionability items. Items are rated as yes, no, or not applicable and converted to a percentage. Higher scores indicate better health literacy.35 Good understandability and actionability were defined using a cutoff score of 70%.36

Health care professional resources

Content of health care professional resources was compared to the Canadian consensus on six appropriateness criteria for TJA:11 1) OA symptoms negatively impact quality of life, 2) evidence of OA on examination (clinical and radiographic), 3) trial of conservative treatment, 4) achievable expectations, 5) patient and surgeon agree that potential benefits outweigh potential risks of surgery, and 6) patient is physically and mentally ready for TJA. Criteria were scored as being present or absent for a possible total score of six.

To evaluate the extent to which SDM is supported in TJA decision-making processes, content of health care professional resources was also evaluated against eight key elements of SDM: the resource a) encourages explicitly the use of SDM, b) defines/explains the problem, c) creates choice awareness (equipoise, explicitly states decision), d) encourages learning about the patient (e.g., patients’ preferences and values, check/clarify understanding), e) encourages awareness of health care professionals’ knowledge/recommendations, f) encourages making the decision (document discussion about decision and the decision itself, make or explicitly defer decision, patients retain ultimate authority over decision, revisiting decision), g) encourages tailoring information (ascertain preferred format for information, flexibility and individualized approach, use clear language), and h) encourages deliberation (negotiation).37,38 Elements were scored as being present or absent in resources with a total possible score of eight.

Data analysis

Main characteristics of resources for patients and health care professionals were descriptively synthesized. Findings for patient resources (IPDAS, PEMAT-P and PEMAT-A/V) were analyzed using median, inter-quartile range (IQR), and range. Findings for health care professional resources (Canadian consensus on six appropriateness criteria for TJA, key elements of SDM) were analyzed using median, IQR, and range.

Results

Characteristics of resources

Of a total of 184 Web sites and 1,647 Google results searched, 84 resources were included and analyzed (Figure 1). Of those, 71 resources were developed for patients, 11 for health care professionals, and 2 for both patients and health care professionals. Out of the 71 patient resources, four were patient decision aids (meeting all seven IPDAS defining criteria; IDs 1, 2, 3, 4), one a patient clinical practice guideline (ID 71), and 66 were patient information material (IDs 5–70). Out of the 11 health care professional resources, 1 was categorized as health care professional information material (ID 83), 1 an assessment form (ID 79), 4 referral forms (IDs 75, 77, 78, 82), 1 a clinical practice recommendations document (ID 80), 1 a model of care document (ID 84), and 3 were quality of care materials (IDs 74, 76, 81). The two resources for both patients and health care professional (IDs 72, 73) were clinical practice guidelines. Most resources were written content in Web pages (n = 37), followed by videos (n = 21), and downloadable booklets (n = 15). Resources were last updated between 2011 and 2021 (Table 1).

Figure 1. PRISMA diagram of resources searches.

Figure 1

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Table 1.

Main Characteristics of Resources

ID Resource Name Delivery From Developers Last Updated Scores
Patient decision aids IPDAS (/7) PEMAT U; A (%)
 1 Arthritis: Should I have knee replacement surgery? Interactive online AB, BC, SK Healthwise 2020 7 94;80
 2 Arthritis: Should I have hip replacement surgery? Interactive online AB, BC, SK Healthwise 2020 7 94;80
 3 Deciding about hip replacement surgery Video AB Healthwise 2020 7 90;100
 4 Deciding about knee replacement surgery Video AB Healthwise 2020 7 91;100
Patient information IPDAS (/7) PEMAT U; A (%)
 5 The surgery journey Web page AB, NB, NL, NS Arthritis Society 2019 5 81;80
 6 All about your hip: preparation for surgery Video SK Ministry of Health 2015 5 83;100
 7 Osteoarthritis Web page AB, BC, SK Healthwise 2020 5 75;40
 8 Osteoarthritis of the hip Web page COA OrthoGate 2015 5 87;20
 9 Osteoarthritis of the knee Web page COA OrthoGate 2015 5 87;20
 10 Hip replacement surgery: how others decided Video AB, SK Healthwise 2020 4 56;0
 11 Knee replacement surgery: how others decided Video AB, SK Healthwise 2020 4 56;0
 12 Osteoarthritis: treating osteoarthritis of the knee Web page NS NS 2014 4 67;40
 13 All about your knee: preparation for surgery Video SK Ministry of Health 2015 4 83;100
 14 Artificial joint replacement of the hip Web page COA OrthoGate 2015 4 87;40
 15 Artificial joint replacement of the knee Web page COA OrthoGate 2015 4 87;40
 16 Knee replacement surgery: pros and cons Video AB Healthwise 2020 3 56;0
 17 Knee replacement surgery Web page AB, BC, SK Healthwise 2020 3 80;40
 18 Total hip replacement surgery Web page AB, BC, SK Healthwise 2020 3 81;40
 19 Deciding about total hip replacement Web page AB Healthwise 2020 3 86;40
 20 Deciding about knee replacement surgery Web page AB Healthwise 2020 3 93;40
 21 Hip replacement (anterior) precautions: what to expect at home Web page AB Healthwise 2021 3 88;60
 22 Knee replacement surgery Web page AB, NB, NL, NS Arthritis Society 2017 3 62;40
 23 Hip and knee arthroplasty patient educational videos Video AB, NB, NS, COA COF 2011 3 82;67
 24 My guide to total knee replacement Booklet PE Queen Elizabeth Hospital 2020 3 81;80
 25 My guide to total hip replacement Booklet PE Queen Elizabeth Hospital 2020 3 81;80
 26 Knee replacement surgery Booklet NS Health Authority 2018 3 88;100
 27 My surgery: orthopaedic surgery patient information: before surgery Web page NS Health Authority NR 3 94;83
 28 Osteoarthritis Web page NS NS 2014 3 67;40
 29 Treatment for osteoarthritis Web page ON, COF, B&J Canada GLA:D Canada NR 3 73;0
 30 Hip replacement surgery Video AB Healthwise 2020 2 64;0
 31 When you are having a knee replacement Web page AB B&J HSCN 2019 2 87;80
 32 Knee replacement: recovery Video AB Healthwise 2020 2 56;67
 33 Hip replacement: before your surgery Video SK Healthwise 2020 2 91;67
 34 Having a hip replacement Web page AB B&J HSCN 2021 2 87;80
 35 Learning about total knee replacement surgery Web page AB Healthwise 2020 2 93;40
 36 Learning about total hip replacement surgery Web page AB Healthwise 2020 2 93;40
 37 Total knee replacement rehabilitation Web page AB Healthwise 2020 2 81;60
 38 Hip replacement (posterior) precautions: what to expect at home Web page AB Healthwise 2020 2 93;60
 39 Hip replacement surgery: returning home Video AB Healthwise 2020 2 73;100
 40 Hip replacement: when can you be active again Video AB, SK Healthwise 2020 2 91;100
 41 Knee replacement surgery Video AB, SK Healthwise 2020 2 60;0
 42 Hip replacement surgery Web page AB, NB, NL, NS Arthritis Society 2017 2 54;40
 43 Planning for maximal results: preparing for your surgery Booklet AB, NB, NS, COA COF NR 2 71;67
 44 Get moving: Maximizing your activity after a hip or knee replacement Booklet AB, NB, NS, COA COF NR 2 65;83
 45 Tips for recovery after hip replacement Booklet AB, NB, NS, COA COF NR 2 73;67
 46 Hip and knee video by Dr. Mike Evans Video AB, NB, NS, COA COF 2013 2 67;67
 47 My surgery: orthopaedic surgery patient information: In hospital Web page NS Health Authority NR 2 93;80
 48 NSHA patient education videos: hip and knee surgery full video Video NS Health Authority 2017 2 82;100
 49 Patient and coach information total hip replacement Booklet SK Health Authority 2018 2 88;83
 50 Patient and coach information total knee replacement Booklet SK Health Authority 2018 2 88;83
 51 Osteoarthritis treatments Web page AB, NB, NL, NS Arthritis Society 2021 2 53;40
 52 Patient journey: osteoarthritis Web page AB, NB, NL, NS Arthritis Society 2020 2 83;40
 53 Total hip replacement Web page AB, NB, NS, COA COF NR 2 46;0
 54 What to expect before surgery Web page AB, NB, NS, COA COF NR 2 64;40
 55 What to expect during and after surgery Web page AB, NB, NS, COA COF NR 2 62;40
 56 Artificial hip dislocation precautions Web page COA OrthoGate 2015 2 87;40
 57 Before your surgery: how to prepare Video AB Healthwise 2020 1 91;100
 58 Knee arthritis: what is knee replacement surgery? Video AB Healthwise 2020 1 83;0
 59 Knee replacement: when can you be active again? Video AB Healthwise 2020 1 91;100
 60 Knee replacement: learning about rehab Video AB, SK Healthwise 2020 1 90;100
 61 Learning about sex after hip replacement surgery Web page AB Healthwise 2020 1 93;60
 62 Returning to sexual activity following joint replacement surgery Booklet AB, NB, NS, COA COF 2017 1 93;60
 63 Total hip replacement patient care pathway Booklet PE Queen Elizabeth Hospital 2018 1 57;20
 64 My surgery: orthopaedic surgery patient information: at home Web page NS Health Authority NR 1 93;80
 65 My surgery: Orthopaedic surgery patient information: family and caregivers Web page NS Health Authority NR 1 83;40
 66 Elective hip replacement post operative exercises Booklet SK Regina Qu’appelle Health Region NR 1 94;100
 67 Elective knee replacement post operative exercises Booklet SK Regina Qu’appelle Health Region NR 1 94;100
 68 Do I need joint replacement surgery? Web page AB, NB, NS, COA COF NR 1 78;60
 69 Hip & knee replacement and you Web page AB, COF B&J Canada NR 1 50;20
 70 Joint replacement: Realistic expectations Web page AB, BC Healthwise 2020 0 67;0
Clinical practice guidelines for patients IPDAS (/7) PEMAT U; A (%)
 71 Patient reference guide: osteoarthritis: care for adults with osteoarthritis of the knee hip or hand Booklet ON Health Quality ON 2018 3 69;40
 72* Quality standards: Osteoarthritis: care for adults with osteoarthritis of the knee, hip or hand Booklet ON Health Quality ON 2018 3 69;0
 73* Quality standard placemat for osteoarthritis Booklet ON Health Quality ON 2020 2 60;20
Health care professionals CAN criteria (/6) SDM (/8)
 74 Hip & knee replacement toolkit: a living document Document AB B&J Canada 2011 5 4
 75 Hip and knee replacement referral Form AB Health Services 2017 4 1
 76 Appropriateness of hip and knee replacement: a system based perspective Document AB B&J Canada NR 4 4
 77 WRHA central intake form for hip and knee joint replacement surgery Form MB Winnipeg Regional Health Authority 2020 3 1
 78 Orthopedic assessment clinic: primary hip and knee arthroplasty referral form Form NS Health Authority 2018 3 1
 79 Osteoarthritis tool Form ON Arthritis Alliance of Canada, Centre for Effective Practice, The College of Family Physicians of Canada 2017 3 3
 80 Quality-based procedures clinical handbook for primary hip and knee replacement Document ON Health Quality ON, Ministry of Health and Long-Term Care 2013 3 3
 81 Health care professionals: when to get a consultation for hip or knee replacement surgery Document AB B&J Canada NR 3 2
 82 Hip and knee multi-disciplinary clinics referral form Form SK Government of SK 2017 2 0
 83 Shared decision making: AB hip & knee osteoarthritis program Video AB AB Bone and Joint Health Institute 2021 0 6
 84 Health care professionals: osteoarthritis Web page AB B&J Canada NR 0 1
Health care professionals and patients
 72* Quality standard: osteoarthritis: care for adults with osteoarthritis of the knee, hip or hand Booklet ON Health Quality ON 2018 5 7
 73* Quality standard placemat for osteoarthritis Booklet ON Ontario Health 2020 3 4
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*

ID 72 and 73 target patients and health care professionals and therefore are appraised under both types

A = Actionability; AB = Alberta, BC = British Columbia, B&J = Bone & Joint, CAN = Canadian, COA = Canadian Orthopaedic Association, COF = Canadian Orthopaedic Foundation, HSCN = Health Strategic Clinical Network, NB = New Brunswick, NL = Newfoundland and Labrador, NR = not reported, NS = Nova Scotia, ON = Ontario, PE = Prince Edward Island, U = Understandability, SK = Saskatchewan.

Quality appraisal of patient resources

The median number of IPDAS defining criteria met for the 73 patient resources was 2 out of 7 (IQR 1, min-max 0–7) (online supplementary Table 1). Criteria most met were identifying the target audience (97%), describing the health condition related to the decision (60%), and supporting values clarification for outcome of options (45%). Criteria least met were listing alternative options (27%), stating the decision to be made (16%), and providing benefits (11%) and harms (10%) of alternative options. Four patient resources met all IPDAS criteria to be defined as a patient decision aid (IDs 1, 2, 3, 4), and the median number of IPDAS criteria for bias minimization and quality was 5 out of 6 (IQR 1.3, min-max 4–6) and 12.5 out of 23 (IQR 15, min-max 5–20) respectively (Figure 2). Without the four decision aids, the 69 other resources met a median of 2 of 7 IPDAS criteria (IQR 1, min-max 0–5).

Figure 2.

Figure 2

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Patient resources compared to IPDAS defining criteria (N = 73).

Median PEMAT understandability score was 83% (IQR 23%, range 46–94%) (online supplementary Table 2). Fifty-one resources (70%) achieved good understandability (defined as a score of ≥70%). Items most frequently met by the resources were: not asking users to perform calculations (100%), include clear visual aids (100%), use common language (96%), only use medical terms when needed and they are defined when used (96%), and present information in a logical sequence (96%). Items least frequently met by the resources were: provide a summary (5%), include visual aids with clear titles (59%), and use an active voice (63%). Median PEMAT understandability score for decision aids was 88% (IQR 13%, range 81–94%, all scored ≥70%) and 83% for other resources (IQR 23%, range 46–94%, 64% scored ≥70%).

Median PEMAT actionability score was 60% (IQR 40%, range 0–100%). Twenty-six resources (36%) achieved good actionability (defined as a score of ≥70%). Items most frequently met by the resources were: identify at least one action the user can take (82%), address the users directly (79%), and include visual aids to guide action (41%). Items least frequently met by the resources were: provide explanation on how to use tables and figures (14%), provide a tangible action tool (26%), and break down actions into steps (39%) (Figure 3). PEMAT actionability item “instruction for calculations” was not applicable for all resources. Median PEMAT actionability score for decision aids was 80% (IQR 0%, range 80–80%, all scored ≥70%) and 40% for other resources (IQR 40%, range 0–100%, 30% scored ≥70%).

Figure 3.

PEMAT score of patient resources (N = 73).

Figure 3

VA = visual aid.

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Quality appraisal of health care professional resources

The median number of Canadian consensus appropriateness criteria met by health care professional resources was 3 out of 6 (IQR 1, range 0–5) (online supplementary Table 3). Criteria most frequently met were: evidence of OA (77%), trial of conservative treatments (77%), and OA symptoms negatively impacting quality of life (54%). Criteria the least frequently met were: patients physically and mentally ready for surgery (8%), patients have achievable expectations (31%), and patients and surgeons agree that benefits outweigh risks (46%) (Figure 4).

Figure 4.

Health care professional resources compared to the six Canadian appropriateness criteria for TJA (n = 13).

Figure 4

OA = osteoarthritis.

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The median number of SDM key elements met was 3 out of 8 (IQR 3, range 0–7) (online supplementary Table 4). Key elements most frequently met were: define the problem (77%), create choice awareness (54%), and encourage learning about the patient (39%). Key elements least frequently met were: encourage SDM (15%), be aware of health care professional knowledge/recommendations (23%), encourage deliberation (23%), and tailoring of information (23%) (Figure 5).

Figure 5.

Health care professional resources compared to SDM key definition elements (n = 13).

Figure 5

SDM = shared decision-making.

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Discussion

This environmental scan of publicly available online TJA Canadian resources identified 73 resources for patients considering TJA, with only four meeting the definition of a patient decision aid. There were 13 resources for health care professionals, and none met all six Canadian consensus appropriateness criteria for TJA.

Of the numerous patient education materials on TJA, only four were structured in a way to help patients consider their options (benefits/harms) and reach a decision based on their preferences. These decision aids developed by Healthwise were used in three provinces (Alberta,39, 40, 41, 42 British Columbia,43,44 Saskatchewan45,46), indicating a gap in available decision aids in other provinces. The other resources met few of the decision aid criteria. Previous systematic reviews have reported that patients were more likely to have improved knowledge, reduced decisional conflict, and more likely to participate in decision-making with decision aids compared to usual care.18 However, these patient decision aids are available in only three provinces and not in French.21 Our findings highlight the need and opportunity for access to decision aids for all Canadians.

The other patient resources identified are focused on TJA surgery only and do not provide information on alternative options (e.g., pharmacotherapy, physiotherapy, weight loss) and their associated benefits and harms indicating a gap in information provided to patients. This is problematic because there are several treatment options for patients with OA and consent legislation requires that patients are aware of alternative options.22 This is particularly important given sub-optimal use of conservative treatments for OA prior to considering TJA.47 Previous Canadian studies revealed 47% patients at TJA assessment clinics were referred to conservative treatments48 and 40% of patients scheduled for knee TJA had not tried conservative treatments.49 Patients require resources with full lists of alternative treatment options including benefits and harms to support their decision-making21 early in the disease process to support timely OA management. To support these conversations, models of care need to integrate these tools into practice.

Most included patient resources were understandable for diverse health literacy levels, but few provided a summary of key points or achieved high actionability scores. Consequently, patients with lower health literacy levels would most likely have difficulty transferring knowledge into meaningful actions or making an informed decision.50,51 Previous studies demonstrated that lower health literacy impacts quality of self-management,52 knowledge about surgery and perioperative care instructions,53,54 increases orthopaedic surgery disparities, and influences overall quality and safety of care.53 There is an opportunity to improve actionability of resources by identifying actions that patients can do based on the information presented, breaking actions into manageable steps, and providing tools to help with transferability of actions in patient life.

A recent clinical practice guideline recommends SDM with adults considering TJA.55 TJA is a treatment option among many others, with no single best option.9,56 However, health care professional resources poorly met key elements of SDM. TJA decision-making resources for health care professionals were limited to traditional criteria for determining TJA appropriateness: evidence of OA and trial of conservative treatments.8–10 However, appropriateness also needs to include the patient's perspective (e.g., shared agreement that benefits outweigh harms, expectations, physically and mentally ready for surgery).57 This is particularly important given that up to 34% of patients are dissatisfied after hip and knee TJA2,3,10,58 often because of unrealistic expectations.3,59,60 Most resources did not explicitly encourage health care professionals to learn about patient preferences in the TJA decision-making process nor encourage them to consider patient perspectives and expectations in determining TJA appropriateness indicating a gap in SDM. Given that none of the 13 identified resources for health care professionals met all 6 Canadian consensus appropriateness criteria for TJA, there is opportunity for creating resources that are more inclusive of these criteria. These online resources should be optimized to achieve the Triple Aim of Healthcare (increase patient satisfaction, enhance quality of care, and decrease health care expenditure).61

Strengths and limitations

This study has strengths and limitations to consider. The search strategy was exhaustive and completed systematically in all Canadian provincial/territorial health care Web sites and referred Canadian health care organizations. However, it is possible that some online resources were missed due to the changing nature of Web sites. Furthermore, resources appraised in this study are limited to publicly available online resources and do not include all resources used in clinical practice in Canada. Therefore, study results might not be representative of resources used in clinical practice. Quality appraisal was done by two independent authors with disagreements being resolved through consensus. Finally, the small number of health care professional resources identified is likely due to resources being available in private sections of Web sites available only to those with specific credentials. Therefore, results of health care professional resources appraisal are only representative of what is available publicly.

Conclusion

This environmental scan of publicly available online TJA Canadian resources for patients considering TJA and health care professionals participating in the decision-making process identified 84 resources with 4 considered patient decision aids. Most patient resources are understandable for different levels of health literacy but lack actionable strategies patients can take. The four decision aids identified are of good quality. However, the other patient resources are not designed to support patients in making quality decisions. Health care professional resources include traditional criteria to determine TJA appropriateness but poorly meet other appropriateness criteria and key elements of SDM. There are opportunities for developers of patient resources to focus on designing resources that support informed decision-making of adults and actionable resources, while health care professional resources should consider patients’ perspectives.

Key Messages

What is already known

Few patients with hip or knee OA considering TJA typically receive information on TJA (e.g., procedures, outcomes, rehabilitation) and other available treatments options, which can lead to uninformed decision-making and dissatisfaction with surgery results.

What this study adds

This study identified practice gaps and opportunities for improvement in publicly available online TJA Canadian resources for patients and health care professionals considering TJA. Most patient resources do not support a quality decision while health care professional resources suggest traditional criteria to determine TJA appropriateness and poorly support patients in making the decision.

Funding Statement

L Pacheco-Brousseau is supported by the Arthritis Society PhD Salary Award (#21-0000000085) and matched funding from the University of Ottawa and LPB's co-supervisors’ research funds (2021–2023), the Ontario Graduate Scholarship Program (2021–2022), and a University of Ottawa Admission Scholarship (2019–2023). LPB also received support from the Hans K. Uhthoff MD FRCSC Graduate Fellowship (#712240301930; 2022), the Queen Elizabeth II Graduate Scholarships in Science and Technology (2019–2020), the University of Ottawa Excellence Scholarship (2019–2020), the Eastern District of the Ontario Physiotherapy Association (#712140302327, 2020; #712200305332, 2021), and the Ordre professionnel de la physiothérapie du Québec (2019). DS holds a University Research Chair in Knowledge Translation to Patients. The funding bodies had no role in the design, preparation, review, approval, or any other decisions pertaining to the study.

Supplemental Material

References

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