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
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
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).
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
- Social support needs extend and change across the continuum of
- Must address varying types of needs (tangible, informational,
validation needs, emotional needs).11,12
- Well-defined supportive behavior preferred.12
- Quality is more important than quantity.11,13
- 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.
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
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
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.
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
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: Length of
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
|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: Patients discharged home. Abbreviation: SNF, skilled
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: Patients reaching ambulation
target. Abbreviation: Pts, patients.
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
Transfer-out-of-bed postoperatively. Abbreviations: Pts, patients; TOOB,
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: Overall quality of care.
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: Confidence and readiness for home. Abbreviation:
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
|Figure 8: Trending improvement over time.
Abbreviation: MGO-SSS, Modified Groningen Social Support Scale.
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
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
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.
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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
Correspondence should be addressed to: Christine G. Tea, RN, MSN, Inova
Health System, 3600 Joseph Siewick Dr, Fairfax, VA 22033