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Background: Total knee arthroplasty (TKA) is a successful and common procedure. However, 6-28% of patients are dissatisfied postoperatively. The provision of preoperative patient information, inquiring about patients' expectations, and taking a psychiatric history are essential parts of both preoperative evaluation and postoperative outcome. The aim of this study was to investigate how orthopaedic knee surgeons in Sweden inform their patients before surgery., Methods: A questionnaire was distributed to all knee surgeons performing TKA in Sweden. Responses were received from 60 of the 65 orthopaedic departments performing TKA in Sweden (92%), covering 219 of the approximately 311 knee surgeons at the 65 departments (70%). The answers were analysed with descriptive statistics. A content analysis of the surgeons' opinions was also performed using a thematic method., Results: In terms of information provision, 58% of the surgeons always gave written information while 92% informed orally. Only 44% always asked about the patient's expectations, and only 42% always informed patients about the 20% dissatisfaction rate after TKA. Additionally, 24% never operated on mild indication of arthrosis, 20% always took a psychiatric history, and half never or seldom consulted a psychiatrist. However, all the knee surgeons believed in a psychiatric impact on TKA outcome. Qualitative analysis revealed five common causes of patient dissatisfaction, which in descending frequency were: patients' expectations, choice of patients to operate on, surgical factors, combinations of factors, and insufficient information provision to patients., Conclusions: Knee surgeons in Sweden have considerable awareness of the importance of preoperative patient information, the impact of patient expectations, and psychiatric illness. However, they need to improve their preoperative routines when it comes to providing written information, asking about the patient's expectations, and psychiatric assessment.

Background and Purpose: The number of national arthroplasty registries is increasing. However, the methods of registration, classification, and analysis often differ., Methods: We combined data from 3 Nordic knee arthroplasty registers, comparing demographics, methods, and overall results. Primary arthroplasties during the period 1997-2007 were included. Each register produced a dataset of predefined variables, after which the data were combined and descriptive and survival statistics produced., Results: The incidence of knee arthroplasty increased in all 3 countries, but most in Denmark. Norway had the lowest number of procedures per hospital-less than half that of Sweden and Denmark. The preference for implant brands varied and only 3 total brands and 1 unicompartmental brand were common in all 3 countries. Use of patellar button for total knee arthroplasty was popular in Denmark (76%) but not in Norway (11%) or Sweden (14%). Uncemented or hybrid fixation of components was also more frequent in Denmark (22%) than in Norway (14%) and Sweden (2%). After total knee arthroplasty for osteoarthritis, the cumulative revision rate (CRR) was lowest in Sweden, with Denmark and Norway having a relative risk (RR) of 1.4 (95% CI: 1.3-1.6) and 1.6 (CI: 1.4-1.7) times higher. The result was similar when only including brands used in more than 200 cases in all 3 countries (AGC, Duracon, and NexGen). After unicompartmental arthroplasty for osteoarthritis, the CRR for all models was also lowest in Sweden, with Denmark and Norway having RRs of 1.7 (CI: 1.4-2.0) and 1.5 (CI: 1.3-1.8), respectively. When only the Oxford implant was analyzed, however, the CRRs were similar and the RRs were 1.2 (CI: 0.9-1.7) and 1.3 (CI: 1.0-1.7)., Interpretation: We found considerable differences between the 3 countries, with Sweden having a lower revision rate than Denmark and Norway. Further classification and standardization work is needed to permit more elaborate studies.

Background: Hospital-specific variation in outcome is generally considered to be an important source of information for clinical improvement. We have measured the magnitude of this variation., Methods: We determined the revision risk in 37,642 cemented primary total knee arthroplasties inserted as a result of osteoarthritis from 1993 through 2002 at 93 hospitals in Sweden. We used 2 essentially different methods to estimate risk of revision: a fixed-effects model (Cox's proportional hazards model) and a random-effects model (shared gamma frailty model)., Results: The 2 models ranked hospitals differently. As expected, the fixed-effects model provided more dispersed estimates of hospital-specific revision rates. In contrast to the random-effects model, chance events can easily cause overly optimistic or pessimistic outcomes in the fixed-effects model. Although the revision risk varied significantly between hospitals, the overall revision risk was still low., Interpretation: Assessment of variation in outcome is an important instrument in the continuing effort to improve clinical care. However, regarding revision rate after knee arthroplasty, we do not believe that such analyses necessarily provide valid information on the current quality of care. We question their value as information source for seeking personal healthcare.

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county. The purpose was to evaluate the effects of a diagnosis related groups (DRG)-intervention on the quality of care as perceived by patients at two surgical clinics in the County Council of Gävleborg, Sweden. The study was planned as a nonequivalent control groups design, but external factors turned it into a prospective longitudinal design. Changes in patient experiences of received care were evaluated for the period 1992-1996. Of the 40 included consecutive patients per year from each hospital, > 85% completed the questionnaire. The selection of patients was defined by diagnoses and surgical treatments, and by geographical area. The results demonstrated a decrease of the quality of care as seen from the patient perspective, especially with respect to treatment by staff. Previously stated DRG goals were partially fulfilled and the DRG-intervention was gradually implemented. Other presumed causal variables were: other reforms, restrained resources, quality assurance activities, organizational and structural changes within the county council. Further studies of the effects of health care reforms would yield more distinct conclusions, provided it would be possible to evaluate interventions prior to full-scale implementation.