title: Socio-economic position has no effect on improvement in health-related quality of life and patient satisfaction in total hip and knee replacement: a cohort study.
abstract: BACKGROUND
  Considerable evidence suggests that patients with more advantaged Socio-Economic Positions undergo Total Hip and Knee Replacement (THR/TKR) more often, despite having a lower need. We questioned whether more disadvantaged Socio-Economic Position is associated with an lower improvement in Health-Related Quality of Life (HRQoL) and a lower patient satisfaction after THR/TKR.
  
  
  METHODS
  Patients who underwent primary THR/TKR in one academic and three community hospitals between 2005 and 2009, were eligible for inclusion. The highest completed levels of schooling were aggregated to index social class. We compared the improvement in HRQoL and postoperative satisfaction with surgery (measured using the Short-Form 36 (SF36) and an 11-point numeric rating scale of satisfaction) between the aggregated groups of highest completed levels of schooling, using linear mixed model analysis, with center as a random effect and potential confounders (i.e. age, gender, Body Mass Index and Charnley's comorbidity classification) as fixed effects.
  
  
  RESULTS
  586 THR patients and 400 TKR patients (40% of all eligible patients) agreed to participate and completed all questionnaires sufficiently. We found no differences in HRQoL improvement in any dimension of the SF36 in THR patients. Patients with a higher completed level of schooling had a larger improvement in role-physical (9.38 points, 95%-CI:0.34-18.4), a larger improvement in general health (3.67 points, 95%-CI:0.56-6.79) and a smaller improvement in mental health (3.60 points, 95%-CI:0.82-6.38) after TKR. Postoperative patient satisfaction did not differ between different highest completed level of schooling groups.
  
  
  CONCLUSIONS
  Completed level of schooling has no effect on the improvement in HRQoL and patient satisfaction in a Dutch THR population and a small effect in a similar TKR population. Undertreatment of patients with more disadvantaged Socio-Economic Position cannot be justified, given the similar improvement in HRQoL and postoperative level of satisfaction with surgery between the social groups examined.
authors.affiliation: Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands. j.c.keurentjes@lumc.nl
authors.forename: J Christiaan
authors.initials: JC
authors.lastname: Keurentjes
authors.forename: David
authors.initials: D
authors.lastname: Blane
authors.forename: Melanie
authors.initials: M
authors.lastname: Bartley
authors.forename: Johan J B
authors.initials: JJ
authors.lastname: Keurentjes
authors.forename: Marta
authors.initials: M
authors.lastname: Fiocco
authors.forename: Rob G
authors.initials: RG
authors.lastname: Nelissen
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires