title: Where is the patient in models of patient-centred care: a grounded theory study of total joint replacement patients.
abstract: BACKGROUND
  Patient-centered care ideally considers patient preferences, values and needs. However, it is unclear if policies such as wait time strategies for hip and knee replacement surgery (TJR) are patient-centred as they focus on an isolated episode of care. This paper describes the accounts of people scheduled to undergo TJR, focusing on their experience of (OA) as a chronic disease that has considerable impact on their everyday lives.
  
  
  METHODS
  Semi-structured qualitative interviews were conducted with participants scheduled to undergo TJR who were recruited from the practices of two orthopaedic surgeons. We first used maximum variation and then theoretical sampling based on age, sex and joint replaced. 33 participants (age 38-79 years; 17 female) were included in the analysis. 20 were scheduled for hip replacement and 13 for knee replacement. A constructivist approach to grounded theory guided sampling, data collection and analysis.
  
  
  RESULTS
  While a specific hip or knee was the target for surgery, individuals experienced multiple-joint symptoms and comorbidities. Management of their health and daily lives was impacted by these combined experiences. Over time, they struggled to manage symptoms with varying degrees of access to and acceptance of pain medication, which was a source of constant concern. This was a multi-faceted issue with physicians reluctant to prescribe and many patients reluctant to take prescription pain medications due to their side effects.
  
  
  CONCLUSIONS
  For patients, TJR surgery is an acute intervention in the experience of chronic disease, OA and other comorbidities. While policy has focused on wait time as patient/surgeon decision for surgery to surgery date, the patient's experience does not begin or end with surgery as they struggle to manage their pain. Our findings suggest that further work is needed to align the medical treatment of OA with the current policy emphasis on patient-centeredness. Patient-centred care may require a paradigm shift that is not always evident in current policy and strategies.
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario M5G 1V7, Canada. fiona.webster@utoronto.ca.
authors.forename: Fiona
authors.initials: F
authors.lastname: Webster
authors.forename: Anthony V
authors.initials: AV
authors.lastname: Perruccio
authors.forename: Richard
authors.initials: R
authors.lastname: Jenkinson
authors.forename: Susan
authors.initials: S
authors.lastname: Jaglal
authors.forename: Emil
authors.initials: E
authors.lastname: Schemitsch
authors.forename: James P
authors.initials: JP
authors.lastname: Waddell
authors.forename: Samantha
authors.initials: S
authors.lastname: Bremner
authors.forename: Melanie Hammond
authors.initials: MH
authors.lastname: Mobilio
authors.forename: Viji
authors.initials: V
authors.lastname: Venkataramanan
authors.forename: Aileen M
authors.initials: AM
authors.lastname: Davis
mesh_terms: D000203:Activities of Daily Living / Q000523:psychology; D000328:Adult; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000523:psychology / Q000592:standards; D019645:Arthroplasty, Replacement, Knee / Q000523:psychology / Q000592:standards; D059350:Chronic Pain / Q000523:psychology; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D059408:Pain Management / Q000523:psychology / Q000592:standards; D018802:Patient-Centered Care / Q000458:organization & administration / Q000592:standards; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data; D013997:Time Factors