Background: Total joint replacement is an accepted, cost-effective,
and underutilized treatment for moderate-to-severe hip and knee arthritis.
Yet, research has suggested that many patients with arthritis are unwilling to
consider total joint replacement surgery. We sought to understand these
patients' unwillingness by exploring the nature of their decision-making
Methods: In-depth interviews were conducted with seventeen
individuals with moderate-to-severe arthritis who were appropriate candidates
for, but unwilling to consider, total joint replacement. The interviews were
analyzed with use of qualitative methods and content analysis techniques.
Results: Symptoms and information sources were the two main factors
influencing patient decision-making. Participants engaged in individualized
processes of trading off perceived costs and benefits. Accommodation to pain
and disability and minimization of the quality-of-life benefit, in view of
decreasing life span, led to a process whereby the threshold at which the
benefits compared with the risks would tilt in favor of total joint
replacement was constantly shifting, a phenomenon we called "the moving
Conclusions and Clinical Relevance: The moving-target
characterization sheds light on patients' conceptions of their arthritis and
on their unwillingness to consider total joint replacement. This process needs
to be considered when developing ways to aid decision-making.