Open Access Highly Accessed Open Badges Research article

Where is the patient in models of patient-centred care: a grounded theory study of total joint replacement patients

Fiona Webster1*, Anthony V Perruccio2, Richard Jenkinson3, Susan Jaglal4, Emil Schemitsch5, James P Waddell6, Samantha Bremner7, Melanie Hammond Mobilio1, Viji Venkataramanan8 and Aileen M Davis9

Author Affiliations

1 Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario M5G 1V7, Canada

2 Arthritis Program, Division of Orthopaedic Surgery, University Health Network and Institute of Health Policy, Management & Evaluation, 399 Bathurst Street, EW1-449, Toronto, Ontario M5T 2S8, Canada

3 Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, MG 361, Toronto, Ontario M4N 3M5, Canada

4 Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G 1V7, Canada

5 Division of Orthopaedic Surgery, St. Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, Ontario M5C 1R6, Canada

6 Division of Orthopaedic Surgery, St. Michael’s Hospital, 38 Shuter Street, 3rd floor, Room 3005, Toronto, Ontario M5B 1A6, Canada

7 Faculty of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8, Canada

8 Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, 399 Bathurst Street, MP11-324, Toronto, Ontario M5T 2S8, Canada

9 Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, 399 Bathurst Street, MP11-322, Toronto, Ontario M5T 2S8, Canada

For all author emails, please log on.

BMC Health Services Research 2013, 13:531  doi:10.1186/1472-6963-13-531

Published: 23 December 2013



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.


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.


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.


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.

Osteoarthritis; Hip and knee replacement; Models of care; Qualitative methods; Patient experiences of care; Patient-centered care