Orthopedics

Feature Articles 

The Connection Between Strong Social Support and Joint Replacement Outcomes

Mark M. Theiss, MD; Michael W. Ellison, MS; Christine G. Tea, RN, MSN; Julia F. Warner, RN, MSN; Renee M. Silver, RN, MSN; Valerie J. Murphy, RN, MSN

Abstract

A myriad of emotional, informational, and tangible needs can easily overwhelm patients as they seek to navigate a complicated surgical procedure. This article demonstrates that a dedicated family member or friend supporting their loved one before, during, and after joint replacement surgery measurably impacts quality and outcomes. The multidisciplinary, multihospital study team developed the following Opportunity Statement: “To define, measure, and implement a progressive family/friend support system across the continuum of care promoting optimal patient recovery after total joint arthroplasty.” The team used the modified Groningen Orthopedic Social Support Scale to measure levels of social support and associated these levels with other patient outcomes.

Analysis of 1722 observations across 4 hospitals found that patients with strong social support have shorter hospital stays, are more likely to be discharged home, to meet ambulation and transfer-out-of-bed targets, and to score hospital quality of care higher, and are more confident and ready to go home on discharge. Three presence intervals were also found to be significant predictors of key outcome measures: family/friend presence during the preoperative classes, in the preoperative holding area, and during the last physical therapy session. These intervals may serve as reasonable social support proxies for organizations desiring to measure social support to ultimately affect quality and outcomes.

Contemplating surgery can be daunting. Shortened hospital stays add to anxiety and make it difficult to ensure that patients have the education and support necessary to properly prepare for upcoming surgery and ultimately to help them achieve the best possible surgical outcomes. Several studies in the literature demonstrate the positive effects of preoperative education, while others show how strong social support helps patients during hospitalization and the postoperative recovery period. A multidisciplinary, multihospital team wanted to determine if this knowledge could be used to benefit orthopedic patients.

Previous studies have clearly demonstrated a link between social relationships and patient outcomes. Social support, measured in various ways, has been shown to be associated with mortality,1 mental health,2 stress,3 and depression.4 Most recently, a study by Mitchinson et al3 demonstrated associations between social support and depression, anxiety, pain, opiate use, and length of stay among major thoracic/abdominal surgery patients. The authors concluded that “limited social connectedness impacts negatively on the quality and rate of recovery after major operations, regardless of postoperative complications.” They reported that patients with limited social connectedness will likely require additional pain medication and vigilance by physicians and caregivers.3

Prouty et al5 studied total joint replacement patients and found a positive relationship between preoperative education and postoperative levels of pain and anxiety, so much so that they felt that patients should be encouraged to bring a family member, caregiver, or “coach” to the preoperative education class to be better prepared pre-, peri- and postoperatively.5 Results from Jester,6 Johansson et al,7 and Ottenbacher et al8 also support various elements of the “coach” concept.

van den Akker-Scheek et al9 noted that perceived social support was an important factor in a joint replacement patient’s recovery and that hospital nurses tended to determine the amount of social support a patient had by the number of visitors they had. They developed a tool, the Groningen Orthopaedic Social Support Scale, to reliably measure social support for arthroplasty patients in Holland. They later developed the Groningen Orthopaedic Exit Strategy.10 They hypothesized that “higher self-efficacy, more social support, and better pain-coping result in a quicker and more efficient rehabilitation, which must become noticeable in an improved ability to resume activities of daily living, a higher level of physical activity, and a better health-related quality of life.” They developed a 6-month support program for all patients deemed eligible for the…

Abstract

A myriad of emotional, informational, and tangible needs can easily overwhelm patients as they seek to navigate a complicated surgical procedure. This article demonstrates that a dedicated family member or friend supporting their loved one before, during, and after joint replacement surgery measurably impacts quality and outcomes. The multidisciplinary, multihospital study team developed the following Opportunity Statement: “To define, measure, and implement a progressive family/friend support system across the continuum of care promoting optimal patient recovery after total joint arthroplasty.” The team used the modified Groningen Orthopedic Social Support Scale to measure levels of social support and associated these levels with other patient outcomes.

Analysis of 1722 observations across 4 hospitals found that patients with strong social support have shorter hospital stays, are more likely to be discharged home, to meet ambulation and transfer-out-of-bed targets, and to score hospital quality of care higher, and are more confident and ready to go home on discharge. Three presence intervals were also found to be significant predictors of key outcome measures: family/friend presence during the preoperative classes, in the preoperative holding area, and during the last physical therapy session. These intervals may serve as reasonable social support proxies for organizations desiring to measure social support to ultimately affect quality and outcomes.

Contemplating surgery can be daunting. Shortened hospital stays add to anxiety and make it difficult to ensure that patients have the education and support necessary to properly prepare for upcoming surgery and ultimately to help them achieve the best possible surgical outcomes. Several studies in the literature demonstrate the positive effects of preoperative education, while others show how strong social support helps patients during hospitalization and the postoperative recovery period. A multidisciplinary, multihospital team wanted to determine if this knowledge could be used to benefit orthopedic patients.

Previous studies have clearly demonstrated a link between social relationships and patient outcomes. Social support, measured in various ways, has been shown to be associated with mortality,1 mental health,2 stress,3 and depression.4 Most recently, a study by Mitchinson et al3 demonstrated associations between social support and depression, anxiety, pain, opiate use, and length of stay among major thoracic/abdominal surgery patients. The authors concluded that “limited social connectedness impacts negatively on the quality and rate of recovery after major operations, regardless of postoperative complications.” They reported that patients with limited social connectedness will likely require additional pain medication and vigilance by physicians and caregivers.3

Prouty et al5 studied total joint replacement patients and found a positive relationship between preoperative education and postoperative levels of pain and anxiety, so much so that they felt that patients should be encouraged to bring a family member, caregiver, or “coach” to the preoperative education class to be better prepared pre-, peri- and postoperatively.5 Results from Jester,6 Johansson et al,7 and Ottenbacher et al8 also support various elements of the “coach” concept.

van den Akker-Scheek et al9 noted that perceived social support was an important factor in a joint replacement patient’s recovery and that hospital nurses tended to determine the amount of social support a patient had by the number of visitors they had. They developed a tool, the Groningen Orthopaedic Social Support Scale, to reliably measure social support for arthroplasty patients in Holland. They later developed the Groningen Orthopaedic Exit Strategy.10 They hypothesized that “higher self-efficacy, more social support, and better pain-coping result in a quicker and more efficient rehabilitation, which must become noticeable in an improved ability to resume activities of daily living, a higher level of physical activity, and a better health-related quality of life.” They developed a 6-month support program for all patients deemed eligible for the short-stay program; these patients were discharged on postoperative day 5.

While the literature shows that social support could play a significant role in the success of an arthroplasty patient’s recovery, no studies articulate the role of a coach and how a coach could provide the necessary social support to help ensure successful and rapid recovery.

A review of literature provided an adequate foundation for studying social support. The study team hypothesized that internal outcome measures would be associated with varying levels of social support and that a coach may be an effective means to strengthen social support levels. Representation on the study team included orthopedic nurses, rehabilitation specialists, a physician, and an outcomes analyst. The team developed the following Opportunity Statement: “To define, measure, and implement a progressive family/friend support system across the continuum of care promoting optimal patient recovery after total joint arthroplasty.”

Materials and Methods

Using a plan–do–check–act quality methodology, the team outlined the following key objectives: define social support, measure to quantify current levels of social support and assess correlations to outcomes, determine root cause theories for inadequate social support, and implement a strategy to improve social support (Table 1).

Table 1

To develop an internal working definition of social support, the team drew from their findings in the literature and solicited input from other total joint centers to guide in identifying key attributes that describe social support. Literature review suggested that optimal social support had 5 important attributes:

  1. Social support needs extend and change across the continuum of care.
  2. Must address varying types of needs (tangible, informational, validation needs, emotional needs).11,12
  3. Well-defined supportive behavior preferred.12
  4. Quality is more important than quantity.11,13
  5. Independence should always be the goal.

The following questions helped guide which measures were valuable to collect: What is the level of social support for our joint replacement patients? Are family/friends present at key points before and after surgery (surgeon’s preoperative office visit, preoperative class, surgery preoperative holding, last physical therapy class in hospital, during discharge instructions)? Is level of social support associated with mobility achievement postoperatively, length of stay, morbidity rates, patient satisfaction, confidence and readiness for discharge, or discharge destination?

To capture the elements of social support as defined above, the team selected the Groningen Orthopedic Social Support Scale, a 12-item self-reporting tool. It was developed and tested for validity and reliability in the Netherlands and designed specifically for the total hip and knee arthroplasty population. Approval for usage was obtained by contacting 1 of its authors. A few modifications were made, with permission, to allow for application in context. The English translation of the tool was used and the response scale was modified for enhanced sensitivity and scale balance. The tool’s verb tense and wording was also slightly modified to assess how prepared patients were for postdischarge social support. The original tool was designed to assess social support either during or after hospital stay. The team used it on the day of discharge. With the exception of 1 question, agreement analysis demonstrated (using kappa statistics) that sufficient agreement was present between day-of-discharge perception and actual postdischarge social support 1 week later. For reference purposes, the modified tool was called the Modified Groningen Social Support Scale (MGO-SSS). In addition to the 12 MGO-SSS questions, the team added 2 additional outcome indicators: overall patient satisfaction and confidence and readiness to go home. Finally, 5 family/friend presence indicators were added to later associate with the total MGO-SSS score. Although the original Dutch version was found valid and reliable, future testing is recommended for the English version with the modified questions/response scales. Table 2 contains the MGO-SSS.

Table 2

Premier Quality Manager (Premier, Inc, Charlotte, North Carolina), a risk-adjustment analytics program, was used to assess the impact of social support level on length of stay, complication rates, and morbidity rates. Premier uses proprietary disease-specific risk-adjustment models developed from approximately 600 hospitals and 14 million patient records to adjust for >15 patient factors.

Other measures, such as ambulation, transfer-out-of-bed, and discharge status, were captured manually and entered into Microsoft Access (Microsoft Corp, Redmond, Washington) relational databases. SAS analytical software (SAS Institute Inc, Cary, North Carolina) was used to compile, analyze, and report results.

Four hospitals conducted initial measurement using the MGO-SSS. From a scale of 0 (no social support) to 100 (optimal social support), the average total score was 87.2 (ranging by hospital from 85.9 to 88.9). The original development of the Groningen Orthopedic Social Support Scale did not define acceptable thresholds of performance. By comparison, however, a 2007 study published by the Orthopedic Department of the University Medical Center Groningen, Netherlands,10 reported a control group total score for hip/knee replacements of 70.1 (n=103). Comparative ability, however, may be suspect since the study measurement occurred on day of admission versus day of discharge, and our team used a slightly modified version of the tool. Nonetheless, the study team believed that attaining higher levels of social support was achievable. A goal of >90 was established.

Four common theories were revealed using a cause and effect analysis determining when family/friend support is inadequate (Table 1). The third and fourth root cause theories were largely considered outside the control of the team. Although physicians and patients could be educated and encouraged to solicit family/friend support, the ultimate decision of family/friend involvement was up to the patient.

A substantial portion of the implementation plan, therefore, addressed the first and second root cause theories since the team could more clearly define what social support looks like and elevate its value and importance among patients, families, and physicians. To impact the root cause theories, the team developed the following strategies, which were designed to define and raise awareness of sufficient social support, especially from a quantitative and literature-based perspective. The effectiveness of the strategy rested primarily with the physician: If it was a priority to the physician, it would become a priority to the patient.

Results

Over a 24-month period, a convenience sample of 1722 primary hip and knee patients was captured on the day of discharge. This represents a response rate of 30% (1722/5834).

Scores from the MGO-SSS were scaled from 0 (no support) to 100 (very high support). These were also categorized into 4 levels: 0-32, no/low support; 33-66, moderate support; 67-89, high support; 90-100, very high support. Modified Groningen Social Support Scale scores were then associated with key outcome measures. Caution should be exercised for strata with low sample sizes.

Length of stay was lower for patients with high or very high levels of social support (t test, P<.0001). This finding was generally consistent across hospitals, procedures, and sexes (Figure 1, Table 3).

Figure 1
Figure 1: Length of stay, unadjusted.

Table 3

Risk-adjusted length of stay also demonstrated better outcomes for patients with high levels of social support (Figure 2). Premier Quality Manager was used and controlled for more than 15 patient characteristics. Expected length of stay was based on the top 16% best hospitals nationally, as identified by Premier. Extreme outliers were removed and geometric means were used. Patients with high and very high levels of social support observed lower than expected lengths of stay (P<.05). Differences in risk-adjusted morbidity (serious complications) and mortality were also assessed but not discernable among social support levels due to no mortalities occurring during the 24 months and very low morbidity rates across all social support levels (<1.3%).

Figure 2
Figure 2: Length of stay, severity-adjusted.

The percentage of patients discharged home was greater for patients with higher levels of social support (Mantel-Haenszel chi-square, P<.0001) (Figure 3, Table 4). This finding was generally consistent across procedures, hospitals, and sexes. One hospital was the exception because of their emphasis on discharging all patients home. Inversely, percentage of patients discharged to a skilled nursing facility decreased as social support level increased.

Figure 3
Figure 3: Patients discharged home. Abbreviation: SNF, skilled nursing facility.

Table 4

Ambulation distance postoperatively was assessed. The percentage of patients achieving the ambulation goal was modestly higher for patients with higher levels of social support (Mantel-Haenszel chi-square, P=.0001) (Figure 4, Table 5). This finding was more pronounced for primary hips over primary knees, and for women over men. Two hospitals achieved high ambulation scores across all levels of social support.

Figure 4
Figure 4: Patients reaching ambulation target. Abbreviation: Pts, patients.

Table 5

Transfer-out-of-bed ability postoperatively was assessed. The percentage of patients achieving the transfer-out-of-bed goal was marginally higher for patients with higher social support (Mantel-Haenszel chi-square, P=.0027) (Figure 5, Table 6). This finding was more pronounced for primary hips over primary knees, for women over men, and for 1 hospital.

Figure 5
Figure 5: Transfer-out-of-bed postoperatively. Abbreviations: Pts, patients; TOOB, transfer-out-of-bed.

Table 6

Patients were asked on the day of discharge, “Overall, would you rate the quality of care provided at our hospital as excellent, very good, good, fair, or poor?” The percentage of patients reporting excellent was higher for patients with higher levels of social support (Mantel-Haenszel chi-square, P<.0001). This finding was consistent across procedures, hospitals, and sexes (Figure 6, Table 7).

Figure 6
Figure 6: Overall quality of care.

Table 7

Patients were asked on the day of discharge, “Overall, do you feel confident and ready to go home: completely, mostly, somewhat, or no?” The percentage of patients reporting completely confident and ready to go home was higher for patients with higher levels of social support (Mantel-Haenszel chi-square, P<.0001) (Figure 7, Table 8). This finding was consistent across procedures, hospitals, and sexes.

Figure 7
Figure 7: Confidence and readiness for home. Abbreviation: Pts, patients.

Table 8

After implementation, the team monitored social support over time. Marginal improvement was observed in the total MGO-SSS score, and also in item response for preparation for transportation, meals, and chores. Current levels of social support are high to very high (Figure 8). Additional improvements are planned, particularly around the role of the physician. This role is pivotal in early emphasis of the value and importance of strong social support for the patient.

Figure 8
Figure 8: Trending improvement over time. Abbreviation: MGO-SSS, Modified Groningen Social Support Scale.

Discussion

The results of this study replicated and validated the importance of quality social support for total joint replacement surgery patients. Intervals were identified during the surgical experience at which social support has significant impact on quality metrics and patient outcomes. The outcome measures that were associated with strong social support include length of stay, mobility, perception of care, discharge disposition, and confidence and readiness to be discharged home.

In studying patients with inadequate social support, women accounted for most cases (73%). A contributing reason was that men were more likely to be married than women at the time of surgery, hence having a greater opportunity for optimal social support. Strategies to enhance support for women, particularly older women, merit discussion beyond the scope of this study.

Findings in this study are limited to that of a large retrospective convenience sample (n=1722). While not a randomized prospective study, results proved consistent across 4 hospitals, 2 procedures (primary hip and knee), and the sexes. Although similar to the original tool, further study to evaluate the validity and reliability of the MGO-SSS is recommended. While the literature has demonstrated the benefits of effective social support in other patient populations, extending this analysis to other patient populations would be of value.

It is noteworthy that other benefits of quality social support can result. Nurses and physical therapy staff consistently noted that an effective coach promoted an enhanced safety net and a smoother transition at discharge. Although not directly measured in this study, effective social support was observed to strengthen patient advocacy, reduce patient anxiety, improve management of pain, aid in information retention, and enhance timeliness of meeting patient needs.

Health care is facing its most challenging time. Quality outcomes and transparency of those outcomes achieved in an economical fashion has become an expectation for organizations and physicians alike. These factors will be key for survival as the industry moves into Medicare break-even and other cost-reduction models to provide services. The need for physicians and hospitals to understand the importance of encouraging quality social support from family and friends during the surgical experience is a valuable element in achieving positive patient outcomes, particularly as reimbursement and resources become increasingly constricted. Beyond metrics and cost, quality social support from friends and family is simply the best course for patients.

Conclusion

Key quality and outcome metrics are measurably and consistently improved with the presence of quality social support. These include length of stay (both unadjusted and risk-adjusted), achieving ambulation and transfer-out-of-bed goals, patient perception of overall quality of care, percentage of patients discharged to home, and patient confidence and readiness to go home.

Three intervals were found to be significant predictors of key outcome measures: family/friend presence during the preoperative class, family/friend presence in the preoperative holding area, and family/friend presence during the last physical therapy session. These intervals may serve as reasonable social support proxies for organizations desiring to measure social support to ultimately affect quality and outcomes.

References

  1. Schoenbach VJ, Kaplan BH, Fredman L, Kleinbaum DG. Social ties and mortality in Evans County, Georgia. Am J Epidemiol. 1986;123(4):577-591.
  2. Seeman TE. Social ties and health: the benefits of social integration. Ann Epidemiol. 1996; 6(5):442-451.
  3. Mitchinson AR, Kim HM, Geisser M, Rosenberg JM, Hinshaw DB. Social connectedness and patient recovery after major operations [published online ahead of print November 12, 2007]. J Am Coll Surg. 2008; 206(2):292-300.
  4. George LK, Blazer DG, Hughes DC, Fowler N. Social support and the outcome of major depression. Br J Psychiatry. 1989; (154):478-485.
  5. Prouty A, Cooper M, Thomas P, et al. Multidisciplinary patient education for total joint replacement surgery patients. Orthop Nurs. 2006; 25(4):257-261.
  6. Jester R. Early discharge to hospital at home: should it be a matter of choice? J Orthop Nurs. 2003;7(2):64-69.
  7. Johansson K, Hupli M, Salantera S. Patients’ learning needs after hip arthoplasty. J Clin Nurs. 2002; 11(5):634-639.
  8. Ottenbacher KJ, Smith PM, Illig SB, Fiedler RC, Gonzales VA, Granger CV. Prediction of follow-up living settings in patients with lower limb joint replacement. Am J Phys Med Rehabil. 2002; 81(7):471-477.
  9. van den Akker-Scheek I, Stevens M, Spriensma A, van Horn JR. Groningen Orthopaedic Social Support Scale: validity and reliability. J Adv Nurs. 2004; 47(1):57-63.
  10. van den Akker-Scheek I, Zijlstra W, Groothoff JW, van Horn JR, Bulstra SK, Stevens M. Groningen orthopaedic exit strategy: validation of a support program after total hip or knee arthroplasty [published online ahead of print September 11, 2006]. Patient Educ Couns. 2007; 65(2):171-179.
  11. Hupcey JE. The meaning of social support for the critically ill patient. Intensive Crit Care Nurs. 2001; 17(4):206-212.
  12. Wortman CB, Conway TL. The role of social support in adaptation and recovery from physical illness. In: Cohen S, Syme SL, eds. Social Support and Health. Orlando, FL: Academic Press; 1985:286-295.
  13. Koenig HG, Westlund RE, George LK, Hughes DC, Blazer DG, Hybels C. Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals. Psychosomatics. 1993; 34(1):61-69.

Authors

Dr Theiss and Ms Silver are from Inova Fairfax Hospital, Mr Ellison is from Inova Health System, and Ms Tea is from Inova Fair Oak Hospital, Fairfax, Ms Warner is from Inova Mount Vernon Hospital, and Ms Murphy is from Inova Alexandria Hospital, Alexandria, Virginia.

Dr Theiss, Mr Ellison, and Mss Tea, Warner, Silver, and Murphy have no relevant financial relationships to disclose.

The authors thank the developers of the Groningen Orthopedic Social Support Scale for sharing their tool, and Karen Kelly, RN, Maura Mathieson, RN, BSN, Dolores Ritual-Gray, RN, BSN, and Ann Vennell, PT, for their contributions.

Correspondence should be addressed to: Christine G. Tea, RN, MSN, Inova Health System, 3600 Joseph Siewick Dr, Fairfax, VA 22033 (christine.tea@inova.org).

doi: 10.3928/01477447-20110317-02

10.3928/01477447-20110317-02

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