title: Routes to total joint replacement surgery: patients' and clinicians' perceptions of need.
abstract: OBJECTIVE
  To explore patients' perspectives of need for total joint replacement associated with decision making in orthopaedic consultations for hip or knee osteoarthritis.
  
  
  METHODS
  Twenty-six orthopaedic consultations in 3 UK hospitals were observed and audio recorded, and semistructured interviews were conducted with the involved patients and clinicians. Data were analyzed using thematic analysis.
  
  
  RESULTS
  Two main routes to orthopaedic consultation were identified: patients who waited until their symptoms were no longer bearable (holding off), and patients who sought consultation preemptively (before it gets worse). These routes were mediated by age, comparison with others, demands and desires, deterioration, and convenience. Whether patients had held off or sought help preemptively influenced their perceptions of need. Patients' perceptions of their route to orthopaedic consultation, and consequently their perception of need, were either confirmed or contradicted by clinicians.
  
  
  CONCLUSIONS
  When clinicians and patients have differing perceptions of need there may be ongoing patient anxiety, concern, and feelings of disempowerment. It is important for primary and secondary care clinicians to identify and explore a patient's perception of need in order to provide consistency in referral pathways and to support patient involvement in, and understanding of, shared decision making. Exploring the patient's perspective of their route to consultation is proposed as one easily achievable method of identifying patients' views on urgency of their need.
authors.affiliation: University of Bristol, Bristol, Avon, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Sansom
authors.forename: Jenny
authors.initials: J
authors.lastname: Donovan
authors.forename: Caroline
authors.initials: C
authors.lastname: Sanders
authors.forename: Paul
authors.initials: P
authors.lastname: Dieppe
authors.forename: Jeremy
authors.initials: J
authors.lastname: Horwood
authors.forename: Ian
authors.initials: I
authors.lastname: Learmonth
authors.forename: Susan
authors.initials: S
authors.lastname: Williams
authors.forename: Rachael
authors.initials: R
authors.lastname: Gooberman-Hill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000523:psychology*; D019645:Arthroplasty, Replacement, Knee / Q000523:psychology*; D001291:Attitude of Health Personnel; D002755:Choice Behavior; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D009985:Orthopedics; D015207:Osteoarthritis, Hip / Q000523:psychology* / Q000601:surgery; D020370:Osteoarthritis, Knee / Q000523:psychology* / Q000601:surgery; D010342:Patient Acceptance of Health Care; D036301:Qualitative Research; D012017:Referral and Consultation