Perioperative Satisfaction and Health Economic Questionnaires in Patients Undergoing an Elective Hip and Knee Arthroplasty: A Prospective Observational Cohort Study.

Background: Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated.
Methods: We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care.
Results: Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04).
Conclusion: Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients' concerns. Copyright:

INTRODUCTION

Surgery results in some level of patient discomfort and disorientation. Depending on the type of surgery, recovery protocols, and support mechanisms, patients and caregivers often experience anxiety upon discharge. Today, there is increasing interest in earlier discharge for multiple reasons, including patient safety (reduced iatrogenic harms), and reduced bed block, and reduced health system costs,but may result in some trade-offs of increased patient anxiety and some unintended harms displaced to the community. This early discharge can leave medical providers with several concerns, including patient preparedness, expectations, support at home, and overall patient satisfaction with their experience.

With earlier discharge, postoperative recovery care is transferred to patients and their informal caregivers, who can feel overly burdened and anxious.[123] However, patient satisfaction and outcomes can also be positively affected as patients recover at home while easing into activities of daily living in the midst of family and friends.[3] The course of postoperative recovery is influenced by many factors, including patient characteristics, patient expectations, type of surgery and anesthesia, and social factors.[45] The most common reason for unplanned contact with the health-care system after discharge is troublesome postoperative symptoms, such as pain or disability, which can delay the patient's return to normal daily function.[6789]

For a subset of patients, postoperative home care needs to go beyond medication prescriptions and care instructions; for these patients, care needs to be broader to include appropriate and adequate support for addressing recovery at home. Using technology, patients and their caregivers can be empowered with the assurance of continuity and integration of care. Digital solutions with 24 × 7 phone numbers, e-mails, text messages, home monitoring of patients’ signs/symptoms and vital signs, and video chats for medical consultation can provide this continuity of care during the recovery process. Digital patient portals may provide an effective way of improving access for patients and caregivers to address their concerns in a timely manner.[10] Although not every patient wants or is able to use digital solutions, there is broad support for improving the options for connecting care to home while maintaining patient choice.[10]

This prospective study presents the results of surveys of both patient- and caregiver-reported perspectives administered before and after surgery at the London Health Sciences Centre (LHSC), as to whether they were provided with adequate information to inform their preparation for and expectations about recovery, and their satisfaction with the management of postoperative recovery at home. We designed this prospective study to evaluate baseline patient needs and satisfaction with the management of recovery to inform the subsequent design and broader implementation of postoperative home monitoring (POHM) at our institution. Our primary objective was to investigate patient perspectives on the level of preparation in four areas of concern (medications, postoperative pain, the recovery process, and management of side effects) and to assess the level of satisfaction with management of their recovery in the perioperative period. A secondary objective was to assess the level of satisfaction for caregivers and health economic questionnaire during the perioperative period. We aim to use the results to inform subsequent development of POHM tools and techniques that will address patient education, expectations, and postsurgery coping strategies.

METHODS

After approval from the Health Sciences Research Ethics Board, Western University (112127), a quantitative study was conducted from July 2019 to February 2020 at LHSC University Hospital, a tertiary care center in London, Ontario, Canada. We recruited consecutive patients who attended the preadmission clinic (PAC) for scheduled preoperative visits to participate in the study. All patients were given both verbal explanation and written information about the study, and informed consent was obtained from those who agreed to participate in accordance with the Declaration of Helsinki principles. This survey was conducted to formally evaluate baseline patient-reported outcomes before and after the incorporation of a POHM system.

Questionnaire design

We developed four set of questionnaires in this study, which includes preoperative questionnaire, postoperative questionnaire, caregiver questionnaire, and health economic questionnaire. Preoperative and postoperative questionnaires addressed four potential areas of concern for patients undergoing early postsurgical discharge: (1) the recovery process: 12 questions (preoperative 8 and postoperative 4 questions); (2) postoperative pain management: 20 questions (preoperative 14 and postoperative 6 questions); (3) perioperative medications: 15 questions (preoperative 11 and postoperative 4 questions); and (4) management of side effects or postoperative complications: 9 questions (preoperative 5 and postoperative 4 questions) [Appendices 1 and 2].[11]

The preoperative questionnaire (38 questions) was administered to quantify the extent of patient knowledge, expectations, and ability to handle early postsurgical discharge. The postoperative questionnaire (18 questions) sought to understand patient coping and management capability postsurgery and to quantify how well the patient believed their recovery was proceeding. Patient agreement or satisfaction with statements was recorded on a 5-point Likert scale, with a higher score indicating a higher level of patient agreement or satisfaction.

The family care partner or family caregiver's questionnaire (21 questions) with 17 binary responses (yes or no) and four multiple-choice questions was administered postoperatively to understand their ability to cope with patient's recovery at home [Appendix 3]. Health economic questionnaires (54 questions) were developed by health economist AB and JM. This was discussed and approved by the multidisciplinary hospital team [Appendix 4].

Inclusion criteria included adult surgical patients aged >18 years and patients undergoing either elective total hip or knee replacement surgical procedures at the University Hospital. Exclusion criteria included individuals unwilling or unable to give informed consent, patients with acute emergency or revision surgical procedures, patients with insufficient English comprehension or inability to read and write English, and patients with insufficient ability to communicate, such as those with cognitive dysfunction. We also recruited caregivers of patients who consented to participate in our study.

The patients were recruited by the study team over a study period of 8 months for possible study participation during their visit to the preoperative admission clinic prior to their surgical procedure. After obtaining the informed consent, preoperative and postoperative interviews were conducted by the research staff. Following recruitment, patient demographic information was recorded (age, sex, weight, height, BMI, occupation, education, marital status, previous surgery, distance from home to the hospital, family caregivers at home, medical comorbidities, American Society of Anesthesiologists physical status, current surgical procedure, and current medication). All patients were asked to respond to two interviewer-administered questionnaires. The first interview was conducted in person at PAC, before the surgery [Appendix 1]. The second interview was conducted via phone 5–7 days postsurgery with the patient and their caregiver [Appendices 2-4]. The interviews took 20–30 min to complete the questionnaire.

Statistical analysis

Summary statistics were computed for all variables of interest. Means, standard deviations (SD), frequencies, and percentages were used for descriptive statistics. The level of patient concern, preparation, and expectations in the preoperative phase and the level of postoperative satisfaction collected on a Likert scale of 5 were reported as the mean and SD. Paired t-test was used to compare the preoperative scores and postoperative scores to understand the needs versus the satisfaction. To understand the patient centered care, further analyses were conducted to explore whether the patients’ perceptions of needs identified preoperatively and satisfaction with management recovery varied significantly by their demographic (age, gender) and clinical characteristics (hip vs. knee arthroplasty) using independent t-tests and ANOVA. A sample of 239 was considered adequate to detect the correlation coefficient of 0.3 with 95% power, Type 1 error rate of 0.05, and with 20% loss to follow-up. The sample size was calculated by a power analysis (URL: http://www.gpower.hhu.de/ Proper Citation: G*Power (RRID:SCR_013726. A two-tailed P value < 0.05 was considered statistically significant. GraphPad Prism version 8.0.0 for Mac, GraphPad Software, San Diego, California USA, www.graphpad.comwas used for statistical analysis.

RESULTS

Baseline characteristics of the patients and caregivers

The demographic characteristics of the patients and their informal caregivers are presented in Table 1. A total of 284 patients were approached and 239 patients were recruited by the study team over a study period of 8 months for possible study participation during their visit to the preoperative admission clinic prior to their surgical procedure. The preoperative questionnaire was completed by 98.8% of patients, and the postoperative follow-up questionnaire was completed by 94.2% of patients; 75% of informal caregivers completed the postoperative follow-up questionnaire. The mean age of patients was 66.0 ± 11.4 years, and 62.8% were over the age of 65 years. Females constituted 57% of patients. Out of 239 patients, 54.4% of the patients underwent total knee arthroplasty and 45.6% underwent total hip arthroplasty.

Table 1

Baseline characteristics of the patients and caregivers

Variable	Category	n (%)
Patient demographics (n=239)
Age (years)*	<65	89 (37.2)
	≥65	150 (62.8)
Sex	Male	103 (43)
	Female	136 (57)
Surgical procedure	Hip	109 (45.6)
	Knee	130 (54.4)
Preoperative survey completed	Complete	236 (98.7)
	Incomplete	3 (1.3)
Patient follow-up	Yes	225 (94.1)
	No response	11 (4.6)
	Deceased	3 (1.3)
Family caregiver information
Caregiver follow-up	Yes	180 (75.4)
	No response	25 (10.4)
	Declined	15 (6.2)
	Deceased patient	3 (1.3)
	Respite care	10 (4.2)
	Alone at home	6 (2.5)
Caregiver work type	Unemployed	5 (2.1)
	>20 h/week	57 (23.8)
	<20 h/week	16 (6.7)
	Retired	94 (39.2)
	Homemaker	4 (1.7)
	Student	2 (0.8)
	Other	3 (1.3)
Caregiver marital status	Married/common law	150 (62.5)
	Single	19 (7.9)
	Divorced	2 (0.8)
	Widowed	8 (3.3)
Household income	<25 K	13 (5.4)
	25-50 K	24 (10)
	50-75 K	36 (15)
	75-100 K	23 (9.6)
	>100 K	40 (16.7)
	No answer	44 (18.3)
Highest level of education	Elementary	3 (1.3)
	High school	41 (17.1)
	Postsecondary	133 (73.8)

Patients’ preoperative needs/expectations and postoperative satisfaction

Questions relating to perceived adequacy of preoperative information in meeting patient needs and expectations, and postoperative satisfaction related to coping were evaluated using a 5-point Likert scale in four areas of potential concern: the recovery process, postoperative pain management, postoperative medications to be taken, and management of side effects or postoperative complications [Table 2]. Postoperative satisfaction scores (mean score = 4.19 ± 0.2) were higher than preoperative needs/expectation scores (mean score = 3.45 ± 0.4) among patients undergoing both hip and knee surgical procedures. This seems to indicate that patients were able to cope better than they felt they would be able to, when asked before surgery.

Table 2

Patients’ preoperative needs/expectations and postoperative satisfaction

Questionnaires	n	Preoperative needs/expectations, mean±SD	n	Postoperative satisfaction, mean±SD
Perioperative medication management	222	4.17±0.5	222	4.43±0.6
Postoperative pain management	221	3.08±0.9	221	3.84±0.5
Recovery process	219	3.24±1.0	219	4.30±0.4
Side effects and complications	220	3.34±1.1	220	4.20±0.8
Overall mean score		3.45±0.4		4.19±0.2

The patients’ postoperative satisfaction was significantly higher than the preoperative need/expectation across all four categories. SD=Standard deviation

Subdomain analysis

Analysis of the following subdomains were conducted for both preoperative needs/expectations and postoperative satisfaction: perioperative medication, postoperative pain management, recovery process, side effects and complications. Table 2 shows perioperative medication management to have the highest mean score for both preoperative needs/expectations (4.15 ± 0.5) and postoperative satisfaction (4.43 ± 0.6). This suggests that patients felt well informed by information on medication management provided to them before surgery, and subsequently, their scores showed they were satisfied with their ability to manage their medication in the postoperative period. For all the other subdomains and individual subscales, patients indicated only adequate understanding before surgery but interestingly showed a higher satisfaction in the postoperative period, indicating they were better prepared to cope with the recovery process than they felt they had been prior to surgery. With this baseline perioperative experience, approximately half of the patients (51.5%) preferred to go home early or on the day after surgery.

Patients’ preoperative needs/expectations and postoperative satisfaction by age, sex, and surgical procedure

Patients’ preoperative needs/expectations and postoperative satisfaction scores were further examined by age, sex, surgical procedure for perioperative medication and postoperative pain management, recovery process, side effects, and complications [Table 3]. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty. Males appear to have felt better prepared preoperatively with regard to postoperative pain management and also indicated better postoperative satisfaction in managing pain. Males also indicated higher postoperative satisfaction regarding the recovery process.

Table 3

Patients’ preoperative needs/expectations and postoperative satisfaction by age, sex, and surgical procedure

Variable	Category	Preoperative needs, mean±SD	P	Postoperative satisfaction, mean±SD	P
Perioperative medication management (n=222)
Age	<65	4.21±0.56	0.24	4.45±0.66	0.93
	≥65	4.11±0.65		4.44±0.66
Surgery	Hip	4.12±0.67	0.46	4.47±0.61	0.52
	Knee	4.17±0.57		4.43±0.69
Sex	Male	4.19±0.62	0.38	4.51±0.59	0.22
	Female	4.12±0.62		4.39±0.69
Postoperative pain management (n=221)
Age	<65	3.22±0.86	0.12	3.74±0.83	0.12
	≥65	3.01±1.06		3.91±0.77
Surgery	Hip	3.04±0.96	0.47	4.04±0.69	<0.01
	Knee	3.14±1.02		3.70±0.84
Sex	Male	3.25±1.03	0.03	3.98±0.70	0.04
	Female	2.97±0.95		3.76±0.84
Recovery process (n=219)
Age	<65	3.26±1.03	0.78	4.27±0.74	0.45
	≥65	3.22±1.12		4.34±0.68
Surgery	Hip	3.15±1.06	0.26	4.38±0.69	0.30
	Knee	3.32±1.11		4.28±0.70
Sex	Male	3.34±1.14	0.22	4.46±0.61	<0.01
	Female	3.16±1.03		4.22±0.74
Side effects and complications (n=220)
Age	<65	3.48±0.97	0.09	4.23±0.81	0.81
	≥65	3.23±1.21		4.19±0.84
Surgery	Hip	3.33±1.09	0.97	4.26±0.78	0.58
	Knee	3.33±1.16		4.18±0.87
Sex	Male	3.44±1.08	0.17	4.31±0.78	0.12
	Female	3.24±1.16		4.05±0.86

Patients’ preoperative needs/expectations by individual questions and surgical category

Comparison of how well patients undergoing hip versus knee arthroplasty felt they were prepared preoperatively demonstrated a significant difference between the two groups with respect to information on managing postoperative leg stiffness at home [Supplementary Table 1]. Compared to patients undergoing hip arthroplasty, those undergoing knee arthroplasty indicated they were better prepared on how to manage leg stiffness at home (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04).

Supplementary Table 1

Patients’ preoperative needs/expectations by individual questions and surgical category

Preoperative needs/expectations	Surgical category (mean±SD)		Total	P
	Hips	Knees
Understanding of perioperative medications (n=222)
I feel I have enough information regarding what medications to skip on the morning of the surgery	4.58±0.65	4.62±0.69	4.60±0.67	0.66
I feel I have enough information regarding what medications to continue taking on the morning of the surgery	4.54±0.74	4.51±0.82	4.53±0.79	0.77
I feel I have enough information regarding the exact time to take medications I am to continue the morning of the surgery	4.26±0.95	4.27±1.05	4.26±1.01	0.90
I feel I have enough information regarding what medications to skip before the surgery.	4.49±0.72	4.56±0.71	4.52±0.72	0.45
I feel I have enough information regarding the exact number of days before the surgery I am to skip those medications	4.42±0.88	4.60±0.63	4.52±0.77	0.06
I feel I have enough information regarding what medications to restart after the surgery.	3.47±1.36	3.53±1.37	3.50±1.37	0.72
I feel I have enough information regarding how many days after the surgery I am to restart those medications	3.33±1.36	3.29±1.41	3.31±1.39	0.31
I was verbally instructed about perioperative medications	4.04±1.19	4.19±1.06	4.12±1.12	0.21
I was given written instructions about perioperative medications	4.07±1.23	3.97±1.24	4.00±1.24	0.47
I feel that the information regarding the medications should also be explained to the family caregivers	4.02±1.05	4.18±0.99	4.11±1.02	0.21
Understanding of postoperative pain management (n=221)
I feel I have enough information on postoperative pain management	3.06±1.37	3.15±1.37	3.11±1.37	0.59
I feel I have enough information to assess the severity of pain as per the visual analog scale of 1 to 10 (please see the picture attached at the end of this questionnaire where 1 is no pain and 10 is the worst possible pain)	3.84±1.21	4.02±1.08	3.94±1.15	0.25
I feel I have enough information regarding the amount of pain expected on postoperative days 5-7	2.77±1.28	3.03±1.40	2.91±1.35	0.14
I was informed about having some tolerable pain on postoperative days 5-7	2.94±1.33	3.19±1.36	3.07±1.35	0.16
I feel I have enough information regarding the requirement for postoperative pain medications	2.81±1.35	2.97±1.37	2.89±1.36	0.36
I think pain medications are not required continuously throughout the day on postoperative days 5-7	2.84±1.28	2.75±1.34	2.79±1.32	0.59
I think pain medications are required intermittently (as needed) throughout the day on postoperative days 5-7	3.22±1.34	3.36±1.39	3.30±1.37	0.43
I feel I have enough information regarding medications to take for postoperative pain	2.82±1.31	3.02±1.39	2.93±1.36	0.26
I feel I have enough information regarding the dose (how much) of medications to take for postoperative pain	2.66±1.29	2.75±1.33	2.71±1.31	0.57
I feel I have enough information regarding the side effects of medications to take for postoperative pain	2.72±1.28	2.76±1.35	2.74±1.32	0.79
I feel I have enough information regarding the number of days I am required to take medications for postoperative pain	2.62±1.30	2.66±1.33	2.64±1.31	0.82
If the pain is severe/unbearable and not relieved by medication, I feel I have enough information to know how to contact the health-care system	3.64±1.24	3.60±1.31	3.62±1.28	0.82
I feel I have enough information to recognize common side effects associated with postoperative pain medication (such as drowsiness, nausea and vomiting, and itchiness)	3.54±1.26	3.56±1.36	3.55±1.31	0.89
Understanding of the recovery process (n=219)
I feel I have enough information regarding wound care	2.96±1.40	3.09±1.42	3.03±1.41	0.49
I feel I have enough information regarding the healing process	3.03±1.30	3.21±1.04	3.13±1.36	0.30
I was given enough information to carry out exercise after the surgery	3.52±1.21	3.63±1.25	3.58±1.23	0.47
I was given enough information to carry out physiotherapy after the surgery	3.57±1.14	3.63±1.24	3.60±1.19	0.74
I feel I have enough information on how to manage surgical site swelling at home	2.86±1.27	3.20±1.38	3.04±1.34	0.05
I feel I have enough information on how to manage leg stiffness at home	2.78±1.30	3.13±1.35	2.97±1.34	0.04
I feel I have enough information to decide what I am capable of doing at home	3.33±1.20	3.33±1.33	3.33±1.27	0.96
Understanding of the management of side effects or postoperative complications (n=220)
I feel I have enough information regarding postoperative side effects such as postoperative nausea and vomiting, dry mouth, and thirst	3.15±1.31	3.07±1.36	3.11±1.34	0.67
I feel I have enough information regarding some of the postsurgical signs and symptoms that are due to complications (such as fever, chills, etc.)	3.15±1.33	3.23±1.33	3.19±1.33	0.62
I feel I have enough information regarding some of the postoperative signs and symptoms that are due to life-threatening, dangerous complications (such as bleeding)	3.14±1.33	3.30±1.35	3.22±1.35	0.37
I feel I have enough information regarding how to contact the health-care professionals and reach the hospital in case of an emergency	3.86±1.17	3.71±1.30	3.78±1.25	0.37

SD=Standard deviation

Patients’ postoperative satisfaction by individual questions and surgical category

Analysis of postoperative satisfaction with pain management demonstrated a significant difference between the two groups [Supplementary Table 2]. Hip arthroplasty patients reported better satisfaction scores with respect to well-controlled postoperative pain than knee arthroplasty patients (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001), sufficient pain medications prescribed (hip arthroplasty vs. knee arthroplasty: 4.36 ± 1.01 vs. 3.73 ± 1.30; P < 0.001), and pain medications having worked effectively (hip arthroplasty vs. knee arthroplasty: 4.30 ± 0.88 vs. 3.84 ± 1.17; P = 0.002).

Supplementary Table 2

Patients’ postoperative satisfaction by individual questions and surgical category

Postoperative satisfaction	Surgical category (mean±SD)		Total	P
	Hips	Knees
Patient satisfaction with understanding of perioperative medications (n=222)
There was no confusion regarding the medications in the perioperative period	4.55±0.84	4.51±0.91	4.53±0.88	0.69
The patient and their family are satisfied with the oral and written instructions given	4.51±0.78	4.44±0.87	4.48±0.83	0.52
There was easy access to professional help for clarification regarding perioperative medication management	4.34±0.82	4.33±0.90	4.33±0.87	0.94
The medications were stopped and started as per the plan	4.49±0.78	4.39±0.93	4.43±0.87	0.39
Patient satisfaction with postoperative pain management (n=221)
Postoperative surgical pain was well controlled at home with pain scores <4 most of the time	4.07±1.11	3.37±1.51	3.69±1.39	<0.001
Enough medications were prescribed to control postoperative pain	4.36±1.01	3.73±1.30	4.01±1.22	<0.001
The prescribed pain medication worked well (pain decreased after taking the medication)	4.30±0.88	3.84±1.17	4.05±1.08	0.002
There was easy access for professional help to control severe/unbearable pain	4.01±0.93	3.97±1.11	3.99±1.03	0.76
Overall, the educational and professional help regarding postoperative pain management was good	4.41±0.85	4.11±1.13	4.25±1.02	0.03
It was sometimes difficult, but not impossible, for the patient and family to control the postoperative pain at home	3.08±1.55	3.16±1.42	3.13±1.48	0.67
Patient satisfaction with the recovery process (n=219)
I was supported well by family and friends	4.80±0.40	4.35±0.93	4.76±0.49	0.22
I was supported well by health-care professionals	4.30±1.08	4.16±1.11	4.32±0.97	0.69
I was comfortable and in control and felt that I recovered well after surgery	4.05±1.27	3.93±1.23	4.22±1.09	0.34
I did not feel stressed while recovering at home	4.31±1.02	4.12±1.08	3.99±1.25	0.49
Patient satisfaction after discharge regarding side effects or postoperative complications (n=220)
The professional advice provided regarding the side effects and complications was good	4.33±0.88	4.23±1.02	4.21±1.06	0.19
I was confident enough in my ability to tell the difference between side effects and complications	4.30±0.88	4.30±0.98	4.27±0.96	0.45
I was confident enough in my ability to tell the difference between minor and severe complications	4.04±0.95	4.07±1.03	4.3±0.94	0.96
It was easy to access professional help to identify and manage complications	3.20±1.58	3.24±1.51	4.05±0.99	0.84

SD=Standard deviation

Family care partner or family care giver

Most caregivers (90%) in our study felt comfortable managing patients at home after discharge from the hospital. However, 51% of caregivers reported sleep disturbance, and nearly one-fifth of (23%) of caregivers experienced physical strain while taking care of these patients at home during the postoperative period. Of caregivers, 58% had to make some family adjustments and 61% had to make changes to their personal plans. Of caregivers, 58% agreed that there were demands on their time and 53% indicated their leisure or recreational activities were affected during the patient's recovery process at home. Caregivers also reported that they had to make emotional adjustments (46%) and work adjustments (40%) while taking care of patients at home after hospital discharge. The majority of caregivers felt that educational activities (95%) and employment activities (78%) were not affected. A small percentage of caregivers (16%) had to take extra time off work than originally anticipated while continuing to provide care to patients. The majority of caregivers (71%) felt that it was not a burden on family members to take care of the patients at home, and 87% said that it was not overwhelming to provide care in the home atmosphere [Table 4].

Table 4

Family care partner or family caregiver questionnaire

Family caregiver questionnaire (n=180)	Yes, n (%)	No, n (%)
My sleep was disturbed	93 (51)	86 (47)
It was manageable/reasonably comfortable at home after discharge from the hospital	162 (90)	17 (9)
It was a physical strain	43 (23)	136 (75)
There were family adjustments	106 (58)	73 (40)
There were changes in personal plans	110 (61)	69 (38)
There were other demands on my time	106 (58)	35 (19)
There were emotional adjustments	83 (46)	96 (53)
There were work adjustments	72 (40)	107 (59)
There was a financial strain	18 (10)	161 (89)
It was overwhelming for me to provide care in the home atmosphere	21 (11)	158 (87)
Leisure or recreational activities were affected	97 (53)	82 (45)
Educational activities were affected	7 (3)	172 (95)
Employment activities were affected	38 (21)	141 (78)
More time off work was taken than originally anticipated	30 (16)	149 (82)
Taking care of the patient interfered with my activities	71 (39)	108 (60)
Taking care of the patient placed the burden on our own immediate family members	48 (26)	129 (71)

Health economic questionnaire

Postoperative health-care visits

Of patients undergoing elective hip and knee replacement surgical procedures, 224 answered the health economic questionnaires postoperatively. Of these, 96.9% (n = 217) had family doctors and 8.9% (n = 20) also had primary care providers. Of respondents, 16% (n = 36) had visited either their family doctor or primary care provider within 7 days after hospital discharge. Of these 36 patients, 26 (11.6%) visited the doctor once, 5 (2.2%) visited twice, and 5 (2.2%) visited the doctor three times within the first 7 days after discharge from hospital. Of these patients, 98% used a private vehicle to reach the doctor's office, with one-way traveling time of approximately 18 min, spending approximately $10 per visit. On most of these visits, patients were accompanied by family caregivers (44.4%) and the mean time spent in the clinic to complete the consultation was approximately 35 min. Of the patients, 7% (n = 15) visited the emergency department (ED), spending approximately 215 min, and 3% (n = 7) were readmitted to hospital within 7 days after discharge from the hospital.

Other forms of postoperative home services such as home care nursing, personal support workers, registered dietician home visits, physiotherapy or occupational therapy home visits, social worker home visits, meal delivery programs, adult day programs, transportation services and homemaking services were used by <18% of patients. These services took 1–10 h of service and were conducted once a month. The out-of-pocket cost of these services ranged from $20 to $1400, an average of $304.50.

Out-of-pocket medication costs

During the postoperative stage, patients were prescribed medications to help cope with pain or discomfort. Of patients, 57.5% paid for their prescribed medication - an average out-of-pocket cost of $39.57. Over-the-counter medications were purchased by 61.4% of patients who paid, on average, $25.14 (ranging from $2 to $300). Of patients, 15.5% reported other out-of-pocket expenses for erythropoietin, ice wraps, iron pills, parking, cryo cuffs, dressings, bandages, gasoline, osteotomy bag, braces, diapers, sponges, marijuana, stool softeners, and ice packs amounting to average $251.90. About 62.8% of patients paid for their assistive devices or equipment for their condition, of whom 127 patients indicated that the average amount spent was $211.8. The most common assistive devices were crutches or walking sticks (83 patients), walkers (116 patients), and bathroom aids (81 patients). During postoperative rehabilitation, 79% of patients were contacted often or very often by either professional members, family members, or friends checking on them and their recovery [Supplementary Table 3].

Supplementary Table 3

Postoperative health economics questionnaire

Postoperative health economics questionnaire (n=224)	Yes	No	NA
Do you have a family doctor?	217 (96.9)	7 (3.1)	-
During the last 5 days, have you visited your family doctor?	29 (12.9)	191 (85.3)	4 (1.8)
Do you have a primary care provider (other than your family doctor)?	20 (8.9)	204 (91.1)	-
During the last 5 days, have you visited your primary care provider?	7 (3.1)	13 (5.8)	204 (91.1)
During the last 5 days, how many times have you visited your family doctor or primary care provider? (number times)
26 patients=1 time; 5 patients=2 times; 5 patients=3 times	26 patients=1 time 5 patients=2 times 5 patients=3 times
Did a caregiver accompany you to the family doctor or primary care provider?	16 (7.6)	20 (8.9)	187 (83.5)
How did you travel to the doctor’s office?	Taxi=0.9% Private vehicle=98.1% Ambulance=0% Other=1%
How long does it take you to travel one way to the doctor’s office?	Mean±SD=18.68±16.67 min 95% CI=16.49-20.87 min
What was the total cost of a typical visit to the doctor’s office when you consider the following?  Total round-trip transportation costs  Cost of parking  Cost of food  Cost of lodging  Cost of child or dependent care  Other costs	Mean±SD=$9.19±15.46 95% CI=$5.26-13.11
How much time did you usually spend at the family doctor or primary care provider, including time waiting to be seen and time being seen?	Mean±SD=35.37±13.94 min 95% CI=31.99-38.74 min
How much time did you usually spend at urgent care, including time waiting to be seen and time being seen?	n=19 (8.4%) Mean±SD=130.5±85.08 min 95% CI=89.52-171.5 min
How much time did you usually spend at the? After-hours clinic, including time waiting to be seen and time being seen?	n=15 (7%) Mean±SD=70.67±43.30 min 95% CI=46.69-94.64
How much time did you usually spend at other health professionals (physiotherapist, etc.), including time waiting to be seen and time being seen?	n=60 (26%) Mean±SD=56.08±74.58 min 95% CI=36.82-75.35
How much time did you usually spend at the emergency department visit, including time waiting to be seen and time being seen?	n=15 (7%) Mean±SD=215.4±157.2 min 95% CI=166.4-264.3
How much time did you usually spend during a hospital admission, including time waiting to be seen and time being seen?	n=7 (3%) Mean±SD: 115±154.7 min 95% CI=21.53-208.5
In the last 5 days have you had any home-visiting services provide professional health or personal care that are covered by OHIP?	46 (20.5)	168 (75)	10 (4.5)
In the last 5 days have you had any home-visiting services provide professional health or personal care covered by other insurance?	4 (1.8)	211 (94.2)	9 (4)
In the last 5 days have you had any home-visiting services provide professional health or personal care covered by personal expenses?	6 (2.7)	210 (93.8)	8 (3.6)
For the following questions, please answer if you have used any of the services listed, and please indicate the total cost
Homecare nursing	2 (0.9)	222 (99.1)	-
Personal support worker	11 (4.9)	213 (95.1)	-
Registered dietician home visit	-	224 (100)
Physiotherapy or occupational therapy home visit n=7; $119.6±149.3; Range (20-450)	42 (18)	182 (81)	-
Social worker home visits	-	224 (100)
Meal delivery program (e.g., meals on wheels) n=5; $129.8±53.25; 95% CI=63.69-195.9; Range 59-200	7 (3.1)	217 (96.9)	-
Adult day program	4 (1.8)	220 (98.2)
Transportation services	9 (4)	215 (96)
Homemaking services n=15; $85.74±33.61; 95% CI=68.46-103; Range 42.5-160	15 (6.7)	208 (92.9)	1 (0.4)
Other services, please specify  Grocery service  Respite  Landscaping  Gardening, etc.	15 (6)	209 (93)	-
If you have received these services, please indicate how often and how many hours you spent using these services	From 1 h to up to 10 h; once a month service
What was the total estimated out-of-pocket cost for this care in the last 5 days?	n=15 Mean±SD=304.5±382.9 95% CI=92.44-516.5 Range=20-1400
In the last 5 days, did you or someone else, pay for any assistive devices or equipment for your condition?	140 (62.8)	83 (37.2)	-
Please indicate which assistive devices were purchased You may select more than one option  1=83 (21.8); 2=9 (2.3); 3=4 (1); 4=116 (30.5); 5=7 (1.8): 6=2 (0.5); 7=11 (2.8); 8=81 (21.3); 9=40 (10.5); 10=14 (3.6); 11=2 (0.5); 12=0; 13=11 (2.8)
What was the total amount spent on assistive devices or equipment for your condition?	n=127 Mean±SD=211.8±299.3 95% CI=159.2-264.3 Range=8-2539
In the last 5 days, did you or someone else, pay directly for any home modifications to accommodate your needs? This can include modifications to your (the patient’s) home or anyone else’s home	24 (10.8)	198 (88.8)	1 (0.4)
If yes, what was the out-of-pocket cost for these modifications in the last 5 days?	n=18 Mean±SD: 1064±1750 95% CI=193.6-1934 Range=10-5000
In the last 5 days, did you, or someone else, pay directly for any prescription medications?	128 (57.4)	94 (42.2)	1 (0.4)
If yes, what was the out-of-pocket cost for these prescription medications in the last 5 days?	n=118 Mean±SD: 39.57±61.66 95% CI: 28.32-50.81
In the last 5 days, did you, or someone else, pay directly for any nonprescription (over the counter) medications for the patient?	137 (61.4)	85 (38.1)	1 (0.4)
If yes, what was the out-of-pocket cost for these nonprescription medications in the last 5 days?	n=137 Mean±SD: 25.14±34.37 95% CI: 19.33-30.95 Range: 2-300
In the last 5 days, did you [patient] pay directly for any other medical costs?	34 (15.5)	186 (84.5)	-
If yes, what were the costs for? Please specify in the space provided	Erythropoietin, ice wrap, iron pills, parking, cryo cuff, dressing, bandage, Gasoline, Osteotomy bag, brace, diapers, sponge, marijuana, stool softeners, ice packs
If yes, what was the out-of-pocket cost in the last 5 days?	Mean±SD: 251.9±440.7 95% CI: 104.9-398.8
Personal care, such as bathing, dressing, toileting, hair or nail care?	123 (54)	100 (44)
Coordinating care such as making appointments or hiring professional care services?	43 (19)	181 (80)
Medical care such as changing bandages, giving medications, or other procedures?	80 (35)	144 (64)
Household tasks that (you) would normally do if you were in good health, such as cleaning, laundry, shopping meal preparation, or meal clean up?	198 (88)	26 (12)
Transportation that you would normally do if you were in good health, such as shopping, errands, appointments, or social outings. Please do not include transportation for health-care visits these were captured earlier	167 (74)	56 (25)
House maintenance and yard work that you would normally do if you were in good health, such as lawn care, snow removal, gardening, painting, repair work, and other odd jobs.	105 (47)	118 (52)
Managing finances that you would normally do if you were in good health, such as banking, paying bills, or other paperwork	42 (18)	183 (81)
Other tasks that you would normally do if you were in good health, please specify	14 (6)	210 (93)
How often has someone (either professionals or family members or friends) contacted you by phone/text/email/other to make sure you were okay or check in on you?	Not very often: 44 (19) Often: 96 (42) Very often: 84 (37)
In the last 5 days, did your helper have to arrange for someone to look after any dependents (e.g. children) while they were helping you, not including medical visits?	17	207
If yes, how many times did they have to arrange for someone to care for their children or other dependents?	n=15; 5 (1-7)

(1) Crutches, cane, or walking stick; (2) Wheelchair; (3) Motorized scooter; (4) Walker; (5) Neck, back, or leg braces or supportive devices; (6) Hand or arm brace; (7) Grab bars; (8) Bathroom aids; (9) Bath or bed lifts or other lifting devices; (10) Grasping tools or reach extenders; (11) Special eating utensils; (12) Personal alarm; (13) Other, please specify. SD=Standard deviation, CI=Confidence interval, NA=Not available, OHIP=Ontario health insurance plan

DISCUSSION

Our study showed that postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Even though patients are satisfied with perioperative care, they may have distinct needs and expectations regarding perioperative medication and postoperative pain management. This study fills an important gap in the literature as there are limited studies available on exploring the patient needs/expectations and satisfaction after undergoing the hip and knee arthroplasty procedure.

It is important to recognize that early discharge for joint replacement surgery remains a relatively new shift in practice, and patients who are now discharged into the community would have in the recent past have been observed in hospital for several days before discharge. While early discharge represents a significant opportunity for improved resource utilization and potential for improved outcomes overall, this also leads to new concerns of the potential for some adverse events arising in the community and displacing responsibility and care into the community without adequate understanding of what supports the patients will require.[12] It is expected that the number of unsupported discharged patients will increase as earlier discharge becomes the norm.[13]

As Erkal et al. suggested, support systems are crucial for patients undergoing joint arthroplasty, as the surgery itself and postoperative recovery and rehabilitation can be extremely stressful for patients and their families.[14] The importance of the family caregiver role during the perioperative period, including recovery at home, has been well emphasized in the literature.[1516] Their responsibilities do not end with escorting patients home after surgery,[17] but thereafter, they assume a comprehensive caregiving role at home. It is imperative that education for patients and their caregivers about the role of the caregiver and their crucial part in the recovery process occurs preoperatively.

Although preoperative information and education are reported as vital components of perioperative care,[18] the literature reports that patients receive little and limited information about preoperative procedures.[19] Fraczyk and Godfrey reported that although patients are generally satisfied with perioperative care, they are less satisfied with the quality and quantity of information provided.[20]

A poorly prepared discharge plan will affect not only the patient's ongoing recovery and health but also the health of the patient's family members and caregivers.[2122] When patients transition from hospital to home following surgery, complications and poorly controlled pain result in a return to the hospital or ED visits. Orthopedic outpatient procedures are now common, and such patients may be expected to have more postoperative pain than those undergoing nonorthopedic outpatient procedures.[23]

Postoperative pain management is a crucial component of the postoperative recovery process. A prospective study by Rawal et al. on patients who underwent ambulatory orthopedic and hand surgeries found that 41% and 37% of patients, respectively, experienced moderate-to-severe pain.[24] McGrath et al. found that 12% of patients with moderate-to-severe postoperative pain reported not receiving adequate instructions regarding prescribed analgesics, 14% of them reported receiving inadequate information on adjusting their analgesic regimen, and almost 10% of those patients requested advice from the on-call nurse for intractable pain.[25] The risk of readmission increases with age, and males are more likely to be readmitted than females.[26] Delayed recovery and readmissions caused by the presence of postdischarge symptoms may increase both direct and indirect costs, which include delays in the return to work, time taken off (for both the patient and caregiver), and opportunity cost burdens. In fact, indirect costs may constitute a significant economic burden for caregivers.[27]

Although a study by Manohar et al. did not obtain data on preoperative patient expectations of recovery, postoperative follow-up revealed that full recovery was not achieved even at 30 days postoperatively, and symptoms of pain, tiredness, and muscle aches may have contributed to this delay in full recovery.[23] Young et al. found that even after 10 days, patients were experiencing tiredness, wound problems, difficulty moving around, and hence, difficulty with childcare and other household tasks.[28] Patients reported problems assessing their own condition and knowing what is normal, which highlighted the importance of discharge support. A retrospective analysis of patients undergoing ambulatory surgery revealed that patient satisfaction scores were higher and that less medical attention was sought by patients receiving adequate perioperative care information.[29]

An observational study assessing patient and caregiver burdens after outpatient surgery showed that 21% of primary caregivers noted emotional disturbances, 40% noted physical strain, 42% reported sleep disturbances, and 37% of the caregivers’ noted changes in personal plans while providing postoperative home care for the patients. Caregivers took an average of 1.9 days off work, and 5% reported needing to take more time off from work than originally anticipated. Overall, 26% of the caregivers believed that they sacrificed moderately or a great deal to care for the patients.[23] Another study reported that, on average, caregivers took 4 days off work, as they were involved in home caregiving for an average of 3.5 days.[30]

In our descriptive study, patient and caregiver perceptions on the adequacy of information provided on various aspects of pain management, recovery process and medications provided to them before surgery, and satisfaction with that knowledge in helping them manage their recovery after surgery were explored for patients undergoing hip and knee arthroplasty. The findings of this study demonstrated that although patients are generally satisfied with perioperative care, they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Caregivers also reported some unexpected changes in their work schedules and interference with personal activities arising from patient care.

Ninety percent of the caregivers in our study felt that they had an uncomfortable home experience after the patient was discharged from the hospital. Our more detailed questions revealed that over 50% of the caregivers reported sleep disturbance and additional personal demands, such as changes in personal plans, need for family adjustments, and interference with leisure and recreational activities. Twenty-one percent of the caregivers reported interference with employment activities, 40% required work adjustments, and 16% ended up taking more time off work than originally anticipated.

The assessment of patient and caregiver expectations and burden after discharge is of paramount importance. Although not directly addressed in our study, record-keeping is another burden that caregivers have to bear because of the fragmentation of the health-care system. Family caregivers are often frustrated that health-care providers involved in different aspects of a patient's care do not always communicate with one another, resulting in caregivers having to retell a patient's story and spend unnecessary time clarifying information during ED visits. It would help both caregivers and health-care providers to have a clear point of contact that ensures that patients’ needs are met at every segment of their surgical journey.[10] Despite the positive feedback from the patients about the quality of care in the hospital, they still face challenges with transitional and postoperative care, as the Canadian health-care system is fragmented, with poorly integrated services.[10]

Knoll and Johnson carried out in-depth interviews with eight spousal caregivers of short-stay cardiac surgery patients and found that caregivers often did not receive adequate information, which would have otherwise allowed them to form realistic expectations and would have helped them deal with their uncertainty.[30] The caregivers who did receive adequate information outlining the recovery process felt less stress and anxiety. Mitchell found that patients and their caregivers had three main concerns: wound care, pain relief, and returning to normal activities. It was recommended that improved patient education before surgery and postdischarge telephone calls from the day surgery unit would do much to alleviate these problems.

We believe that a virtual care option that can extend the continuity of care after discharge is a viable solution to this problem by remotely monitoring the patient's vital signs, symptoms, and behavior at home, sending medication reminders, monitoring medication use, and improving patient outcomes. Continuity of care after discharge has been shown to reduce readmissions and ED visits after a variety of surgical procedures.[313233] Mobile application-based follow-up care after ambulatory breast reconstruction has been shown to avert unscheduled in-person follow-up visits during the first 30 days postoperatively and improve patient convenience without affecting complication rates and patient satisfaction.[34] This finding is important, as a common criticism of virtual postoperative care is whether it can truly replace in-person care in terms of patient safety and satisfaction. Improving patient convenience without compromising satisfaction is a strong favorable point for building a patient-centered virtual health-care system that supports smooth postoperative recovery. Another observational study demonstrated that overall patient satisfaction with a telehealth model of postoperative care after liver transplant surgery was extremely high. Increased surveillance and education with this kind of postoperative virtual care is widely appreciated in creating greater awareness and understanding of recovery after surgery.[35]

There are some limitations to our study. Although the number of patients included in this study was relatively large, the patients in this study were recruited from only one center, which would limit the generalizability of our findings. One of the most important limitations is the lack of validation survey questionnaires. It is not known what would be a ‘clinically meaningful’ score for preoperative and postoperative survey results and whether small numeric differences in the pre- and post-operative scores are clinically relevant. There may also be variations in the reported patient needs and satisfaction depending on other factors, such as time of the year and relationship with the surgeon and center. Hence, further studies from diverse centers may be helpful in addressing these limitations.

With the increasing amount and complexity of day surgery increasing, it is important that patients and their caregivers feel confident about postoperative care. This study is an important first step in improving support for patients and caregivers in the recovery process by understanding patient and caregiver perspectives on how well prepared they were preoperatively and how that helped them cope with early postoperative home recovery. In general, patients reported a lower level of preparedness in some domains, but overall postoperative feedback was positive, patients and caregivers showed a high ability to cope with recovery. The next step is to improve preoperative information support based on this feedback and to enhance continuity of care postsurgery through enhanced virtual care options.

CONCLUSION

In this prospective observational cohort study, we explored the perioperative satisfaction in patients undergoing an elective hip and knee arthroplasty. The finding of this study demonstrated that the patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding the perioperative medications and postoperative pain management. To adequately prepare patients and care partners, to provide appropriate home care, the focus of perioperative care should include planning for the shift from hospital to home care. This study reports high levels of patient needs and satisfaction and adds to the body of knowledge on perioperative care instruction for patients undergoing elective hip and knee arthroplasty.

Financial support and sponsorship

This study was supported by the Opportunities Fund of the Academic Health Sciences Centre Alternative Funding Plan of the Academic Medical Organization of Southwestern Ontario (AMOSO; Grant No.: S18-001) and Lawson Internal Research Fund (LIRF; Grant No.: IRF-06-18).

Conflicts of interest

There are no conflicts of interest.

For each of the following statements please indicate your level of agreement from STRONGLY DISAGREED to STRONGLY AGREE=5 using a checkmark (✓) or an ✗

UNDERSTANDING OF PERI-OPERATIVE MEDICATIONS	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1. I feel I have enough information regarding what medications to skip on the morning of the surgery	□	□	□	□	□
2. I feel I have enough information regarding what medications to continue taking on the morning of the surgery	□	□	□	□	□
3. I feel I have enough information regarding the exact time to take medications I am to continue the morning of the surgery	□	□	□	□	□
4. I feel I have enough information regarding what medications to skip before the surgery	□	□	□	□	□
5. I feel I have enough information regarding the exact number of days before the surgery I am to skip those medications	□	□	□	□	□
6. I feel I have enough information regarding what medications to restart after the surgery	□	□	□	□	□
7. I feel I have enough information regarding how many days after the surgery I am to restart those medications	□	□	□	□	□
8. I was verbally instructed about peri-operative medications	□	□	□	□	□
9. I was given written instructions about peri-operative medications	□	□	□	□	□
10. I feel that the information regarding the medications should also be explained to the family caregivers	□	□	□	□	□
11. Are there any other questions/concerns about peri-operative medications not addressed above? If so, please specify in the space provided:
UNDERSTANDING OF POST-OPERATIVE PAIN MANAGEMENT	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1. I feel I have enough information on postoperative pain management	□	□	□	□	□
2. I feel I have enough information to assess the severity of pain as per the visual analogue scale I to 10 (Please see the picture attached at the end of this questionnaire where I is no pain and 10 is the worst possible pain)	□	□	□	□	□
3. I feel I have enough information regarding the amount of pain expected on post-op day 5-7	□	□	□	□	□
4. I was informed about having some tolerable pain on post-op day 5-7	□	□	□	□	□
5. I feel I have enough information regarding the requirement of post-operative pain medications	□	□	□	□	□
6. I think pain medications are not required continuously throughout the day on post-op day 5-7	□	□	□	□	□
7. I think pain medications are required intermittently (as needed) throughout the day on post op day 5-7	□	□	□	□	□
8. I feel I have enough information regarding medications to take for post-operative pain	□	□	□	□	□
9. I feel I have enough information regarding the dose (how much) of medications to take for postoperative pain	□	□	□	□	□
10. I feel I have enough information regarding the side-effects of medications to take for post-operative pain	□	□	□	□	□
11. I feel I have enough information regarding the number of days I am required to take medications for post-operative pain	□	□	□	□	□
12. If the pain is severe/unbearable andnot relieved by medication, I feel have enough information to know how to contact the healthcare system	□	□	□	□	□
13. I feel I have enough information to recognize common side-effects associated with post-operative pain medication (such as drowsiness,nausea and vomiting,and itchiness)	□	□	□	□	□
14. Are there any other questions/concerns about post-operative pain mamagement not addressed above? If so, please specify in the space provided:
UNDERSTANDING OF THE RECOVERY PROCESS	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1. I feel have enough information regarding wound care	□	□	□	□	□
2. I feel have enough information regarding the healing process	□	□	□	□	□
3. I was given enough information to carry outexercise after the surgery	□	□	□	□	□
4. I was given enough information to carry outphysiotherapy after the surgery	□	□	□	□	□
5. I feel have enough information on how to managesurgical site swelling at home	□	□	□	□	□
6. I feel have enough information on how to manage pain is severe/unbearable leg stiffness at home	□	□	□	□	□
7. I feel have enough information to decide what I am capable of doing at home	□	□	□	□	□
8. Are there any other questions/concerns about the recovery process not addressed above? If so, please specify in the space provided:
UNDERSTANDING OF THE MANAGEMENT OF SIDE-EFFECTS OR POST-OPERATIVE COMPLICATIONS	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1.I feel I have enough information regarding post- operative side-effects such as post-operative nausea and vomiting, dry mouth, and thirst	□	□	□	□	□
2. I feel I have enough information regarding some of the post-surgical signs and symptoms which are due to complications (such as fever, chills, etc.)	□	□	□	□	□
3. I feel I have enough information regarding some of the post-operative signs and symptoms which are due to life-threatening dangerous complications (such as bleeding)	□	□	□	□	□
4. I feel I have enough information regarding how to contact the healthcare professionals and reach the hospital in case of an emergency	□	□	□	□	□
5. Are there any other questions/concerns about the management of side-effects or post-operative complications not addressed above? If so, please specify in the space provided:

PATIENT SATISFACTION WITH UNDERSTANDING OF PERI-OPERATIVE MEDICATIONS

Please indicate the patient’s level of agreement using a checkmark (✓) or an ✗	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1.There was no confusion regarding the medications in the perioperative period	□	□	□	□	□
2. Patient and their family are satisfied with the oral and written instructions given	□	□	□	□	□
3.There was an easy access to the professional help for clarification regarding the perioperative medlcation management	□	□	□	□	□
4. The medications were stopped the started as per the plan	□	□	□	□	□
PATIENT SATISFACTION WITH POST-OPERATIVE PAIN MANAGEMENT
Please indicate the patient’s level of agreement using a checkmark () or an X	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1. Postoperative surgical pain was well controlled at home with pain scores < 4 most of the time	□	□	□	□	□
2. Enough medications were prescribed to control the postoperative pain	□	□	□	□	□
3. The prescribed pain medication worked well (pain decreased after taking the medication)	□	□	□	□	□
4. There was an easy access for professional help to control the severe/unbearable pain	□	□	□	□	□
Please indicate the patient’s level of agreement using a checkmark (✓) or an ✗	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
5. Overall, the educational and professional help regarding the postoperative pain management was good	□	□	□	□	□
6. It was sometimes difficult, but not impossible, for the patient and family to control the postoperative pain at home	□	□	□	□	□
PATIENT SATISFACTION WITH THE RECOVERY PROCESS
Please indicate the patient’s level of agreement using a checkmark (✓) or an ✗	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGRE 5
1. I was supported well by family and friends	□	□	□	□	□
2. I was supported well by health care professionals	□	□	□	□	□
3.I was comfortable and in control and felt that I recovered well after surgery.	□	□	□	□	□
4.I did not feel stressed while recovering at home	□	□	□	□	□
PATIENT SATISFACTION AFTER DISCHARGE REGARDING SIDE-EFFECTS OR POSTOPERATIVE COMPLICATIONS
Please indicate the patient’s level of agreement using a checkmark (✓) or an ✗	STRONGLY DISAGREE 1	DISAGREE 2	NEITHER AGREE OR DISAGREE 3	AGREE 4	STRONGLY AGREE 5
1. The professional advice provided regarding the side-effects and complications was good	□	□	□	□	□
2.I was confident enough in my ability to tell the difference between side-effects and complications	□	□	□	□	□
3.I was confident enough in my ability to tell the difference between minor and severe complications	□	□	□	□	□
4. It was easy to access the professional help to identify and manage the complications	□	□	□	□	□
OVERALL EXPERIENCE
Considering my experience, given the option, I would prefer to go home early after surgery:	□	□	□	□	□

Indicate caregiver’s response as TES or NO using a checkmark (✓) or an ✗	Yes	No
My sleep was disturbed	□	□
It was manageable/reasonably comfortable at home after discharge from the hospital	□	□
It was a physical strain	□	□
I was confined to staying at home	□	□
There were family adjustments	□	□
There were changes in personal plans	□	□
There were other demands on my time	□	□
There were emotional adjustments	□	□
There were work adjustments	□	□
There was a financial strain	□	□
It was overwhelming for me to provide care in the home atmosphere	□	□
Leisure or recreational activities wewe affected	□	□
Educational activities were affected	□	□
Employment activities were affected	□	□
Extra time off work was taken then originally anticipated	□	□
Taking care of the patient interfered with my activities	□	□
Taking care of the patient placed the burden on our own immediate family members	□	□

Which of the following statements best describes your employment status?
1. Unemployed
2. Employed less than 20 hours per week
3. Employed 20 hours per week or more
4. Retired
5. Home-maker
6. Student
7. Other
Which of the following best describes your current marital status?
1. Married/Common-Law
2. Single
3. Divorced
4. Widowed
Which of the following best describes your total annual household income before tax?
1. <$35,000 per year
2. $26,000-50,000 per year
3. $51,000-$75,000 per year
4. $76,000-$100,000 per year
5. >$100,000 per year
What best describes your highest level of education?
1. Elementary school
2. High school
3. Post-secondary school (university or college)

1	Do you have a family doctor?	□ Yes □ No □ Not Applicable
2	During the last 5 days, have you visited your family doctor?	□ Yes □ No □ Not Applicable
3	Do you have a primary care provider (other than your family doctor)?	□ Yes □ No □ Not Applicable
4	During the last 5 days, have you visited your primary care provider?	□ Yes □ No □ Not Applicable
5	During the last 5 days, how many times have you visited your family doctor or primary care provider?	__________number of times
6	Did a caregiver accompany you to the family doctor or primary care provider?	□ Yes □ No □ Not Applicable
7	How did you travel to the doctor’s office?	□ Taxi/ride-share □ Private vehicle □ Ambulance □ Other, please specify______________________
8	How long does it take you to travel ONE WAY to the doctor’s office?	___________Minutes
9	What was the total cost of a typical visit to the doctor’s office when you consider the following? • Total round-trip transportation costs • Cost of parking • Cost of food • Cost of lodging • Cost of child or dependent care • Other costs	___________Canadian Dollars
10	How much time did you usually spend at the family doctor or primary care provider, including time waiting to be seen and time being seen?	___________Minutes □ Not Applicable
11	How much time did you usually spend at urgent care, including time waiting to be seen and time being seen?	__________Minutes □ Not Applicable
12	How much time did you usually spend at the? after- hours clinic, including time waiting to be seen and time being seen?	__________ Minutes □ Not Applicable
13	How much time did you usually spend at a specialist visit, including time waiting to be seen and time being seen?	__________Minutes □ Not Applicable
14	How much time did you usually spend at other health professionals (physiotherapist, etc.), including time waiting to be seen and time being seen?	__________Minutes □ Not Applicable
15	How much time did you usually spend at the emergency department visit, including time waiting to be seen and time being seen?	________+Minutes □ Not Applicable
16	How much time did you usually spend during a hospital admission, including time waiting to be seen and time being seen?	___________Minutes □ Not Applicable
17	In the last five days have you had any home-visiting services provide professional health or personal care that are covered by OHIP?	□ Yes □ No □ Not Applicable
18	In the last five days have you had any home-visiting services provide professional health or personal care covered by other insurance?	□ Yes n No □ Not Applicable
19	In the last five days have you had any home-visiting services provide professional health or personal care covered by personal expenses?	□ Yes □ No □ Not Applicable
For the following questions, please answer if you have used any of the services listed, and please indicate the total cost:
20	Homecare nursing	□ Yes □ No___________CAD
21	Personal support worker	□ Yes □ No___________CAD
22	Registered dietician home visit	□ Yes □ No___________CAD
23	Physiotherapy or occupational therapy home visit	□ Yes □ No___________CAD
24	Social worker home visits	□ Yes □ No___________CAD
25	Meal delivery program (e.g. meals on wheels)	□ Yes □ No___________CAD
26	Adult day program	□ Yes □ No___________CAD
27	Transportation services	□ Yes □ No___________CAD
28	Home-making services	□ Yes □ No___________CAD
29	Other services, please specify:___________________________________	□ Yes □ No___________CAD
30	If you have received these services, please indicate how often and how many hours you spent using these services:	□ Daily: If daily, how many hours day did you spend?_____________________ □ At least once a week: If weekly, how many hours a week did you spend?_____________________ □ At least once a month: If monthly, how many hours a month did you spend?_____________________ □ Less than once a month: How many total hours did you spend in the last five days?_____________________ □ Not provided
31	What was the total estimated out-of-pocket cost for this care in the last five days?	___________CAD
32	In the last five days, did you or someone else, pay for any assistive devices or equipment for your condition?	□ Yes □ No
33	Please indicate which assistive devices were purchased. You may select more than one option.	□ Crutches, cane, or walking stick □ wheelchair □ Motorized scooter □ Walker □ Neck, back, or leg braces or supportive devices □ Hand or arm brace □ Grab bars □ Bathroom aids □ Bath or bed lifts or other lifting devices □ Grasping tools or reach extenders □ Special eating utensils □ Personal alarm □ Other, please specify:_______________
34	What was the total amount spent on assistive devices or equipment for your condition?	____________CAD
35	In the last five days, did you or someone else, pay directly for any home modifications to accommodate your needs? This can include modifications to your [the patient’s] home or anyone else’s home.	□ Yes □ No ____________CAD
36	If yes, what was the out-of-pocket cost for these modifications in the last five days?	____________CAD
37	In the last five days, did you, or someone else, pay directly for any prescription medications?	□ Yes □ No
38	If yes, what was the out of pocket cost for these prescription medications in the last five days?	____________CAD
39	In the last five days, did you, or someone else, pay directly for any non-prescription (over the counter) medications for the patient?	□ Yes □ No
40	If yes, what was the out of pocket cost for these non-prescription medications in the last five days?	____________CAD
41	In the last five days, did you [patient] pay directly for any other medical costs?	□ Yes □ No
42	If yes, what were the costs for? Please specify in the space provided:
43	If yes, what was the out of pocket cost in the last five days?	____________CAD
For the following questions, please answer if you required assistance from one or more individuals with the tasks listed. If you answered yes, please indicate how many hours did the person(s) spend assisting you with the following:
44	Personal care, such as bathing, dressing, toileting, hair or nail care?	□ Yes □ No ____________Hours
45	Coordinating care such as making appointments or hiring professional care services?	□ Yes □ No ____________Hours
46	Medical care such as changing bandages, giving medications, or other procedures?	□ Yes □ No ____________Hours
47	Household tasks that [you] would normally do if you were in good health, such as cleaning, laundry, shopping meal preparation, or meal clean up?	□ Yes □ No ____________Hours
48	Transportation that you would normally do if you were in good health, such as shopping, errands, appointments, or social outings. Please do not include transportation for health care visits these were captured earlier.	□ Yes □ No ____________Hours
49	House maintenance and yard work that you would normally do if you were in good health, such as lawn care, snow removal, gardening, painting, repair work, and other odd jobs.	□ Yes □ No ____________Hours
50	Managing finances that you would normally do if you were in good health, such as banking, paying bills, or other paperwork.	□ Yes □ No ____________Hours
51	Other tasks that you would normally do if you were in good health, please specify:____________________________________	□ Yes □ No ____________Hours
52	How often has someone (either Professionals or Family members or Friends) contacted you by phone/text/email/other to make sure you were okay or check in on you?	□ Not very often  □ Often  □ Very often
53	In the last five days, did your helper have to arrange for someone to look after any dependents (e.g. children) while they were helping you, not including medical visits?	□ Yes □ No
54	If yes, how many times did they have to arrange for someone to care for their children or other dependents?	_____________number of times