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

Clark, Jocalyn P. MSc, PhD; Hudak, Pamela L. BScPT, PhD; Hawker, Gillian A. MD, MSc, FRCPC; Coyte, Peter C. PhD; Mahomed, Nizar N. MD, ScD, FRCSC; Kreder, Hans J. MD, MPH, FRCSC; Wright, James G. MD, MPH, FRCSC

Journal of Bone & Joint Surgery - American Volume: July 2004 - Volume 86 - Issue 7 - p 1366–1374
Scientific Articles
Supplementary Content

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.

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:

Copyright 2004 by The Journal of Bone and Joint Surgery, Incorporated
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