This paper describes the results of the initial exploratory phase of a mixed method project to develop practice guidelines for THA and TKA rehabilitation. A pragmatic approach was used to identify recurrent issues and important concepts for each of the broad discussion points in order to inform guideline development and ensure stakeholders' views were captured at the outset. A lack of communication coupled with poor appreciation for each other's roles and expertise appeared to be major issues among our study participants. This was most apparent with family physician-surgeon and PT-surgeon dyads, in less rural communities and between health care settings. Trust was also a dominant factor with many surgeons sharing concerns about the quality and safety of treatment approaches thought to be provided by outpatient PTs; PTs also lacked trust about other PT providers. Lack of trust could potentially be alleviated by improved communication to reduce the misunderstandings, conflicts, inefficiencies and role confusion that may arise and severely hamper patient care and outcomes [15, 32–34]. Different professional training and cultures may explain some of the disparity in how health professionals communicate.
For change to occur, it will require support at both the provider and system level . Greater opportunity for inter-professional dialogue is needed to truly enact team care within programs and across the continuum of care. Patients' perception of poor and inconsistent communication among their healthcare providers can negatively impact patient adherence, confidence, outcomes and satisfaction . Participants in this study spoke to the need for patient-provider communication to improve professionals' understanding of patients' beliefs and preferences and clear, shared expectations regarding rehabilitation outcomes of TJA surgery. Disparities in expectations and evaluation of surgical outcomes are well documented with surgeons tending to rate outcomes more favorably than patients [13, 14]. The intensity and duration of post-operative pain was common yet unexpected among patient participants in our study. Despite this information being readily available through previous studies [37–41], inadequate provider-patient communication and education may once again be at fault. We found there was both uncertainty and disagreement among patient and physician participants concerning professional responsibility for ensuring adequate pain control beyond the immediate post-operative period. Similarly, sleep disturbances described by patients in our study have been previously reported [39, 42] yet not adequately covered in pre-operative education sessions and virtually ignored during the early recovery phase. This was problematic for both patients and their spouses.
Post-operative anxiety, depression, fear and vulnerability were widely reported by patients and of concern to many AHPs. While pre-operative psychological factors were not specifically probed in our study, the literature suggests that pre-operative depressive symptoms are strongly related to post-operative outcomes and satisfaction [37, 38, 41, 43]. Study participants recommended pre-operative screening for depression and other factors that may contribute to protracted pain and psychological distress and improved surgeon awareness of such psychological factors.
Emotional well being including more positive attributes (e.g., self-worth, hope, confidence, empowerment) is increasingly recognized as an important factor in coping and health outcomes of a number of chronic conditions and surgical procedures . Few studies examining the role of patient factors' in determining TJA need and outcomes have included these attitudinal factors in their analyses of important characteristics. Further, current orthopaedic outcome tools fail to capture the concepts of patient attitude, self-efficacy and empowerment  despite the evidence suggesting self-efficacy, for example, impacts patient expectations , long-term functional outcome  and adherence to prescribed exercise . Poor adherence was a commonly held assumption of AHPs in our study and felt to be strongly related to patients' overall attitude about their role and outcome expectations of rehabilitation. Adherence to therapeutic protocols is problematic in many studies of TJA rehabilitation and warrants subgroup analysis to determine whether higher adherence (e.g., greater treatment dosage) results in larger treatment effects. These findings support adoption of self-efficacy theory to guide interventions, such as adopting efficacy enhancing strategies like contracting and role-modeling to enhance patient's confidence regarding the adoption of habits that will support their recovery .
Our findings show that undergoing TJA surgery magnifies the need for support in the short term, consistent with other qualitative reports regarding the value of family and peer support to patients post-operatively . Better social support is associated with lower complication rates, better functional outcomes and higher post-operative quality of life . Patients described feeling supported by health professionals when they were 'heard' and given sufficient time to have their questions and concerns addressed. Similarly, health professionals were most satisfied with their support efforts when they had adequate time to spend with the patient. Surgeons on the whole admitted to having little time to provide the support and guidance sought by most patients and this is equally problematic in Canada and the US.
Concerns about poor health professional support were linked mostly to the follow-up (FU) phase, once supervised rehabilitation was completed. While the patients in our study had a TJA within the past year, several had undergone TJA surgery on another joint previously and expressed their dissatisfaction and feelings of being forgotten after rehabilitation ended. In a survey and chart review of 622 THA patients from three US states, only 41% reported consistent FU visits with their orthopaedic surgeons over a 6-year period and 16% reported they had no FU care . Older individuals and those with lower socioeconomic status were less likely to receive regular FU. Our study patients suggested they would feel more supported in the year following TJA with regular phone calls, drop-in FU clinics with both surgeons and PTs, and group classes to review exercises, monitor progress and address any concerns.
Personal, provider and system-level factors were identified by our study participants as creating barriers to patients' recovery after TJA. Hoppe et al. acknowledged rehabilitation as an important tool in reducing costs of disability regardless of cause . However, with "the rapid proliferation of private rehabilitation services currently operating with little regulation" [pg 18], those using, prescribing and paying for the services are finding it increasingly difficult to determine if in fact, these services are of good quality, justified and cost-effective . In addition to other strategies, routine use of outcome measures and practice guidelines is suggested as a means of justifying and standardizing treatment approaches to address the structure, process and outcomes of the rehabilitation system. Capping the number of visits or duration of rehabilitation may help to control costs but as identified in our study, such limits were felt to hinder the rehabilitation process, ignore individual patient needs, and potentially lead to poorer outcomes and an overall increase in direct and indirect costs .
The issue of timely access to surgical care has been a priority of provincial healthcare ministries in Canada for several years and the focus of several innovative quality improvement strategies [34, 51, 52]. However, little attention and additional funding have been directed toward addressing barriers to quality rehabilitative care following surgery. Access, including transportation concerns, to rehabilitation services continues to be problematic for Canadians and Americans living in more rural settings. Greater use of technology including telerehabilitation (e.g., videoconferencing, remote monitoring) was voiced as a possible solution and deserves further investigation in this patient population .
Sanderson et al. reported clinicians and patients have different perspectives on outcomes and whereas patients' conceptualization of valued outcomes is broad, health professionals tend to focus on pathology and functional disability . We found a similar trend with patients describing a wide range of anticipated and expected outcomes covering many dimensions of health and psychosocial well-being while health professionals, in particular physicians and surgeons, focused more on impairment, basic function (e.g. walking, using stairs) and surgical parameters (e.g., fixation of implant). These incongruent views may play a role in the reported discrepancies between patients' and health professionals' evaluation of surgical outcomes in which there are moderate correlations at best between patient and clinician assessment of symptoms and disability .
Few health professionals reported routinely using standardized outcome measures in their surgical and clinical practices, despite considerable support for their use. Participants' negative views on the utility (e.g., meaningfulness of numerical scores) and feasibility of using such instruments in clinical practice (e.g., time to administer and score) contributed to the low rate of standardized outcome evaluation. Jette et al. reported that a lack of support (e.g., technology, staffing) and irrelevant and confusing questions were barriers to routine use . Further, the apparent confusion among health professionals regarding what constituted an outcome measure may have led to underreporting and suggests more education is needed.
Racial differences in patient-provider communication and the expectations and utilization of joint replacement therapy have been described elsewhere [57, 58], however, we could find no published data specific to the experiences of Aboriginal North Americans undergoing TJA. The isolation and lack of access to TJA rehabilitation care described by the one First Nations person living on reserve in our study may reflect geographical, racial or other differences and warrants systematic study, in collaboration with aboriginal communities.
With the overarching views that "hips and knees are two different beasts" and subgroups of patients require different rehabilitation approaches, it is important to avoid a 'one size fits all' approach when designing rehabilitation practice guidelines for a broad target audience.
Strengths of the study
The credibility and trustworthiness of findings were enhanced by using a standardized discussion guide, multiple data sources, peer and member checking, independent coding and maintenance of an audit trail throughout the data collection and analyses phases. This study provides new data on specific inter-professional communication issues and barriers to recovery after TJA and shares insight from two vastly different health care systems. Further, it adds to the research on protracted post-operative pain, sleep disturbance and anxiety well beyond the immediate post-operative stage, which all stakeholders agree are inadequately and inconsistently managed. The perspectives of patients and health care providers alike are important to ensuring the relevance of practice guidelines, which are extremely time-consuming and expensive to produce  and it is imperative to guideline adoption that all viewpoints be carefully considered.
Due to delays in the ethical review process incompatible with project timelines, only one US site was involved. It is unlikely that we heard the diversity of experiences and health care delivery issues that are inherent in a country with no universal healthcare program and varied access to health insurance. As well, the attitudes, functional limitations, access to specialty care, and rehabilitation experiences of uninsured individuals were not captured and may differ from the individuals in our study. Secondly, physician/surgeon focus groups were challenging to organize and did not include as much practice setting diversity as intended. Physicians' views may not be transferable to those practicing in more rural settings with less access to rehabilitation resources for their patients. Similarly, despite efforts to ensure maximum diversity in patient participants, the experiences of less educated individuals and those not receiving formal rehabilitation services were underrepresented.
There are several take home messages for clinicians, most of which are directly aligned with principles of client-centered practice  aiming to individualize intervention for optimal client outcomes as well as best use of therapeutic resources:
Prior to surgery, ensure patient and provider expectations are clearly communicated and realistic;
Prior to surgery, develop a plan for addressing post-acute pain management, psychological distress and sleep disturbances for several weeks following surgery;
Use strategies to enhance self-efficacy and empower patients to adopt a positive attitude and take an active role in their rehabilitation;
Incorporate efficient approaches to optimize health professional support and follow-up care beyond three months after TJA;
Where possible, engage family members and peers in education, counseling and exercise instruction;
Select meaningful outcome measures and consistently use to evaluate effect of interventions throughout the care continuum and across health care settings.
Future research directions
This study raises a number of questions that could be addressed through future research including an examination of communication and information technologies (e.g., telerehabilitation) on patient-provider and inter-provider communication and delivery of TJA rehabilitation services. Development and testing of a decision aide or screening tool would assist health care providers in identifying patients at risk for protracted pain, emotional distress and functional impairment. Further, there is a need to design, implement and evaluate the effects of a range of FU programs on patient satisfaction and long-term outcomes after TJA.