Patient expectations and patient-reported outcomes in surgery: a systematic review

Perioperative Opioids, the Opioid Crisis, and the Anesthesiologist

This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.

Characterizing preoperative expectations for patients undergoing reverse total shoulder arthroplasty

BACKGROUND

There remains a paucity of information analyzing which factors most influence preoperative expectations for patients undergoing reverse total shoulder arthroplasty (RTSA). The purposes of our study were to characterize preoperative patient expectations for those scheduled to undergo RTSA and to determine the impact of demographic factors, shoulder function, and shoulder pain on these preoperative expectations.

METHODS

Patients were prospectively recruited into the study if they were scheduled to undergo an elective unilateral primary RTSA for a diagnosis of glenohumeral arthritis. Preoperative patient expectations were evaluated using the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Patients also completed the American Shoulder and Elbow Surgeons shoulder score, the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-Upper Extremity computer adaptive test (version 2.0), the PROMIS Pain Interference (PI) computer adaptive test (version 1.1), the PROMIS Depression computer adaptive test (version 1.0), visual analog scores, and an itemized satisfaction questionnaire, which paralleled the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Demographic data and preoperative shoulder range of motion (ROM) were also recorded.

RESULTS

A total of 107 patients scheduled to undergo RTSA were included in the study. Relief of daytime pain (n = 91, 85%), improvement in self-care (n = 86, 80%), and improvement in shoulder ROM (n = 85, 79%) were most commonly cited as "very important" expectations. In the item-specific analysis, lower PROMIS Upper Extremity scores were correlated with greater expectations for the ability to reach sideways (P = .015) and the ability to perform daily activities (P = .018). Patients with lower shoulder ROM had greater expectations for improved shoulder ROM (internal rotation with arm at 90°, P = .004) and an improved ability to perform daily activities (forward elevation, P = .038; abduction, P = .009). In the cumulative analysis, a greater number of very important expectations was associated with African American race (P = .013), higher PROMIS PI score (r = 0.351, P = .004), and lower overall preoperative satisfaction (r = 0.334, P < .001).

CONCLUSION

Patients scheduled to undergo RTSA have the greatest expectations for relief of daytime pain, improvement in self-care, and improvement in shoulder ROM. Patients with limited preoperative ROM have greater expectations for improvement in self-care and the ability to perform daily activities in addition to expectations for improvement in shoulder ROM. Greater overall expectations for surgery were not associated with preoperative physical function but were instead associated with lower preoperative satisfaction and higher PROMIS PI scores.

A qualitative study with orthopaedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery

BACKGROUND

Pain catastrophizing (PC) moderates surgical outcomes and behavioural interventions are recommended to optimise post-operative results. Less is known about surgeons' experiences of providing care and their attitudes towards the use of interventions in practice.

OBJECTIVE

It is therefore invaluable to understand surgeons' views on how best to support patients who may be at risk of suboptimal recovery. Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a hospital setting. The surgical decision-making process, views of PC and the use of behavioural interventions in surgical practice were explored.

RESULTS

Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons' decision-making process, when pathologies and symptoms do not match, psychological factors pertaining to unsatisfactory outcomes, a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery.

CONCLUSION

Orthopaedic surgeons face challenges in identifying who is likely to reach optimal versus suboptimal outcome. Surgeons are becoming increasingly aware of patient psychological distress being detrimental to outcomes, and they support the use of behavioural interventions to optimise post-operative outcomes or stop unnecessary treatments. The surgeons accept the use of a screening tool in surgical practice with better access to support services with input from allied health professionals. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans.

Understanding Patients' Perceived Health After Critical Illness: Analysis of Two Prospective, Longitudinal Studies of ARDS Survivors

BACKGROUND

Perceived health is one of the strongest determinants of subjective well-being, but it has received little attention among survivors of ARDS.

RESEARCH QUESTION

How well do self-reported measures of physical, emotional, and social functioning predict perceived overall health (measured using the EQ-5D visual analog scale [EQ-5D-VAS]) among adult survivors of ARDS? Are demographic features, comorbidity, or severity of illness correlated with perceived health after controlling for self-reported functioning?

STUDY DESIGN AND METHODS

We analyzed the ARDSNet Long Term Outcomes Study (ALTOS) and Improving Care of Acute Lung Injury Patients (ICAP) Study, two longitudinal cohorts with a total of 823 survivors from 44 US hospitals, which prospectively assessed survivors at 6 and 12 months after ARDS. Perceived health, evaluated using the EQ-5D-VAS, was predicted using ridge regression and self-reported measures of physical, emotional, and social functioning. The difference between observed and predicted perceived health was termed perspective deviation (PD). Correlations between PD and demographics, comorbidities, and severity of illness were explored.

RESULTS

The correlation between observed and predicted EQ-5D-VAS scores ranged from 0.68 to 0.73 across the two cohorts and time points. PD ranged from -80 to +34 and was more than the minimum clinically important difference for 52% to 55% of survivors. Neither demographic features, comorbidity, nor severity of illness were correlated strongly with PD, with |r| < 0.25 for all continuous variables in both cohorts and time points. The correlation between PD at 6- and 12-month assessments was weak (ALTOS: r = 0.22, P < .001; ICAP: r = 0.20, P = .02).

INTERPRETATION

About half of survivors of ARDS showed clinically important differences in actual perceived health vs predicted perceived health based on self-reported measures of functioning. Survivors of ARDS demographic features, comorbidities, and severity of illness were correlated only weakly with perceived health after controlling for measures of perceived functioning, highlighting the challenge of predicting how individual patients will respond psychologically to new impairments after critical illness.

A qualitative study to understand patients’ experiences of their post-operative outcomes following forefoot surgery

Background

Hallux valgus and hallux rigidus are two common forefoot conditions causing deformity, pain, functional limitations, disability and deteriorating health status resulting in the requirement for surgery. Even when surgery is performed by an experienced surgeon, there remains a potential for patients to experience dissatisfaction and unfavourable outcomes. Adverse results are moderated by psychosocial variables; however, there is a paucity of qualitative research providing insight into how patients perceive their outcomes and the factors affecting their recovery.

Objective

The study aimed to qualitatively explore patients’ experiences of their surgical outcomes following forefoot surgery and factors associated with their recovery. Semi-structured interviews with 15 patients who received surgery for hallux valgus and/or hallux rigidus were conducted.

Results

Thematic analysis generated five themes: physical limitations, the psychosocial impact of surgical recovery, regaining normality, patients’ expectations for physical recovery and an altered body-image. Physical and psychosocial factors were inter-related. Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. The women reported weight related issues and were limited in their footwear and clothing choices, negatively impacting on their self-esteem.

Conclusion

A forefoot condition is multifaceted, with patients experiencing a range of physical and psychological factors that may influence their outcomes and recovery from surgery. Patients need to be supported holistically with the use of a biopsychosocial model. A multidisciplinary approach to care and treatment within the forefoot surgical pathway with the inclusion of allied health professionals will enable to better support patients to enhance their outcomes.

Should We Perform Early Cataract Surgery? A Patient Reported Outcome Study

Purpose

Current guidance states that access to cataract surgery should not be restricted by visual acuity (VA); nevertheless, 6/12 is used as a cut-off criterion in some health institutions. This study aims to determine the benefits of performing cataract surgery in patients with VA of 6/9 or better in both eyes; determine whether these benefits change over time; and compare the benefit observed between early first eye and second eye surgery.

Patients and Methods

Fifty adults with VA at least 6/9 in the worst eye and no ocular comorbidity were recruited. The Visual Function Index (VF-14) and Impact of Visual Impairment (IVI) questionnaires were conducted pre-operatively, 4 months post-operatively, and 12 months post-operatively. The t-test or a non-parametric equivalent was used to compare averages between groups.

Results

The mean change in VF-14 from baseline to 4 months was 16.43 (95% CI 12.49–20.50, p < 0.001) and the median change in IVI was 6.5 (IQR 9.75, p < 0.001). There was no significant difference between 4-month and 12-month follow-up (p > 0.05). There was no significant difference in the change in visual function between the first and second eye surgery (p > 0.05).

Conclusion

This study provides evidence that visual function improves after cataract surgery in patients with pre-operative VA of 6/9 or better. The improvement observed was clinically significant and unchanged a year after surgery. Visual function improved after second eye as much as after first eye surgery. Assessing patient reported visual function may give a more realistic indication of the benefit of early cataract surgery than relying on VA alone.

Patient-Reported Quality of Life and Satisfaction After Refractive Lens Extraction Using a Diffractive Trifocal IOL: A Multicenter Retrospective Cohort Study

PURPOSE

To assess patient satisfaction and quality of life after refractive lens exchange with a trifocal intraocular lens (IOL).

METHODS

Consecutive patients who underwent refractive lens exchange with the AT LISA tri or AT LISA tri toric IOL (Carl Zeiss Meditec AG) at one of five surgical centers were surveyed for their quality of life and satisfaction after surgery using a standardized questionnaire. Patient responses were compared to patient characteristics such as age, sex, axial lengths, and preoperative refraction.

RESULTS

A total of 102 patients with 204 treated eyes were included in the analysis. The mean age was 54.6 ± 5.2 years. A total of 172 eyes were hypermetropic, 3 were emmetropic, and 25 were myopic, with a mean preoperative refractive error of 0.93 ± 2.17 diopters. Reported postoperative satisfaction was as follows: 81.4% stated that their expectations were completely met and 17.6% stated that they were partially met. Self-reported refractive error quality of life improved significantly in all queried areas of life. Most frequently reported postoperative limitations were driving at night and driving in bad weather conditions. Halos were reported by 91 (90.1%) patients.

CONCLUSIONS

Patient satisfaction and self-reported quality of life after refractive lens exchange with the AT LISA tri or AT LISA tri toric IOL was high. Glare and halos remain the only significant drawback of the procedure, leading to 40% of patients experiencing difficulties in night driving. Preoperative communication of these drawbacks is obligatory to avoid postoperative disappointment. [J Refract Surg. 2021;37(11):768-774.].

Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

OBJECTIVE

Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients' perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.

DESIGN

We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.

SETTING

All participants underwent surgery at a single, academic tertiary-care center.

PARTICIPANTS

Adult patients who had a general surgery operation in the prior 60 days.

OUTCOME MEASURE

Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.

RESULTS

Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.

CONCLUSIONS

Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Evaluation of Patient Expectations before Carpal Tunnel Release

Background:

Carpal tunnel release (CTR) is common, yet patient treatment expectations remain unclear. The primary purpose was to describe patient expectations before CTR. Secondarily, we aimed to identify factors influencing expectations.

Methods:

Included patients underwent unilateral or bilateral CTR between 2015 and 2017 at a single academic center. Expectations regarding the level of relief/improvement were queried. Area deprivation index (ADI) was used to measure social deprivation. Univariate and multivariable logistic regression identified factors associated with expecting great relief/improvement.

Results:

Of 307 included patients, mean age was 54 ± 16 years and 63% were women. Patients most commonly expected great (58%) or some (23%) relief/improvement. Few patients expected little (3%) or no (4%) relief/improvement, and 13% had no expectations. In the multivariable analysis, male sex, lower social deprivation, and lower BMI were associated with expecting great relief/improvement. Age, surgical technique (open versus endoscopic), use of the operating room versus procedure room, and preoperative factors (constant numbness, weakness/atrophy, duration of symptoms, and QuickDASH) were not associated with expectations.

Conclusions:

Most patients expect some to great improvement after CTR. This was independent of several factors with a known association with worse outcomes (advanced age, atrophy/weakness, and constant numbness). Male sex was associated with the expectation of great improvement, in which superior outcomes relative to females have not been borne out in the literature. These findings highlight patient counseling opportunities. The observed association between social deprivation and expectations warrants further investigation, as the socioeconomically disadvantaged experience worse healthcare outcomes in general.

Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses

OBJECTIVE

The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy.

BACKGROUND

Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%.

METHODS

We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer.

RESULTS

Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m² were associated with increased risk for mortality.

CONCLUSIONS

Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.

[Treatment expectations for postoperative pain]

Hintergrund

Präoperative Behandlungserwartungen haben einen deutlichen Einfluss auf die postoperativen Schmerzen und Behandlungsergebnisse. Positive Erwartungen sind ein wichtiger Mechanismus von Placeboeffekten und negative Erwartungen ein wichtiger Mechanismus von Noceboeffekten.

Fragestellung

Welchen Einfluss haben Behandlungserwartungen, wie werden diese im klinischen Setting erhoben und wie können diese Erkenntnisse in der klinischen Praxis umgesetzt werden?

Material und Methoden

Es wurde eine Literatursuche für klinische Studien mit den Schlagwörtern „expectation“ AND („postoperative“ OR „surgery“) durchgeführt. Ausgewählt wurden alle aktuellen englischen und deutschen Artikel. Zusätzlich wurden die Literaturverzeichnisse der gefundenen Artikel untersucht und mit aufgenommen.

Ergebnisse

Insgesamt 158 Artikel wurden gefunden, von denen 49 Artikel Erwartungen erheben und ein postoperatives Behandlungsergebnis einbeziehen. Die meisten Artikel untersuchen Erwartungen in der Baseline-Erhebung, um nachzuweisen, dass sich Gruppen in Gruppenvergleichen präoperativ nicht voneinander unterscheiden. Die Studien, die den Einfluss von Erwartungen prospektiv untersuchen, verwenden sehr unterschiedliche Messverfahren, um das Konstrukt „Erwartung“ zu erheben. Somit ist ein Vergleich zwischen den Studien schwer möglich. Es gibt wenige Studien, die untersuchen, ob und wie die Erwartungen perioperativ beeinflusst werden können, und die praxisrelevante Interventionen zu deren Veränderung entwickelt haben.

Schlussfolgerung

Für eine fundierte Untersuchung der Behandlungserwartung sollten in klinischen Studien valide und reliable Messverfahren verwendet werden. Weitere Studien sollten sich mit Interventionsmöglichkeiten auseinandersetzen, damit Behandlungserwartungen auch in die klinische Standardbehandlung einbezogen werden können.

Hope, Optimism, and Clinical Pain: A Meta-Analysis

BACKGROUND

Generalized expectancies have been theorized to play key roles in pain-related outcomes, but the empirical findings have been mixed.

PURPOSE

The primary aim of this meta-analysis was to quantify the relationships between two of the most researched positive generalized expectancies (i.e., hope and optimism) and pain-related outcomes (i.e., pain severity, physical functioning, and psychological dysfunction) for those experiencing clinical pain.

METHODS

A total of 96 studies and 31,780 participants with a broad array of pain diagnoses were included in analyses, using random-effects models.

RESULTS

Both hope and optimism had negative correlations with pain severity (hope: r = -.168, p < .001; optimism: r = -.157, p < .001), positive correlations with physical functioning (hope: r = .199, p < .001; optimism: r = .175, p < .001), and negative correlations with psychological dysfunction (hope: r = -.349, p = .001; optimism: r = -.430, p <.001).

CONCLUSION

The current findings suggest that hope and optimism are similarly associated with adaptive pain-related outcomes. Future research should examine the efficacy of interventions on hope and optimism in ameliorating the experience of clinical pain.

Thumb Carpometacarpal Arthritis Surgery: The Patient Experience

BACKGROUND

Patients with symptomatic recalcitrant thumb carpometacarpal arthritis often undergo surgery. Although most surgical patients do well, the authors anticipated that a substantial portion of their thumb carpometacarpal surgery patients would have unsatisfactory experiences and express unmet expectations, dissatisfaction, and regret, regardless of surgical procedure performed. The authors hypothesized those experiences would correlate with patient-reported outcomes scores.

METHODS

The authors identified patients who had undergone trapeziectomy alone or with ligament reconstruction 1 to 4 years previously for primary thumb carpometacarpal arthritis. One hundred twelve patients completed Quick Disabilities of the Arm, Shoulder and Hand and visual analogue scale pain, expectations, satisfaction, and regret questionnaires.

RESULTS

More than 40 percent of patients expected to "return to normal" after surgery for pain, strength, and/or function. Including all patients, 7, 19, and 11 percent had unmet expectations for improvement in pain, strength, and function, respectively. Twelve percent expressed dissatisfaction with their outcome. Although just 4 percent regretted undergoing surgery, 13 percent would likely not recommend the procedure to someone they care about. There were no statistically significant differences for any patient-reported outcomes between trapeziectomy-alone (n = 20) and trapeziectomy with ligament reconstruction (n = 92). Visual analogue scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire scores were both moderately correlated with expectations being met for pain, strength, and function and for satisfaction with surgical outcome.

CONCLUSIONS

Patients' thumb carpometacarpal surgical experiences vary considerably. Many express dissatisfaction or a lack of expectations met with the two most common procedures. A thorough understanding and review of expectations preoperatively may be uniquely pertinent for these patients. Further research should determine predictors and potentially modifiable factors for unsatisfactory outcomes.

Top Ten Tips Palliative Care Clinicians Should Know About Trauma and Emergency Surgery

There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.

Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review

Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.

Associations between positive treatment outcome expectations, illness understanding, and outcomes: a cohort study on non-operative treatment of first carpometacarpal osteoarthritis

PURPOSE

More positive outcome expectations and illness perceptions are associated with better outcomes for patients with several osteoarthritic orthopedic conditions. However, it is unknown whether these factors also influence outcomes of non-operative treatment for first carpometacarpal osteoarthritis (CMC-1 OA). Therefore, we assess the role of pre-treatment outcome expectations and illness perceptions in reports of pain and hand function 3 months after non-operative treatment for CMC-1 OA.

MATERIALS AND METHODS

We conducted a cohort study with 219 patients treated non-operatively for CMC-1 OA between September 2017 and October 2018. Patients were included in the study if they completed measures of pain and hand function, illness perceptions (scale: 0-10), and expectations (scale: 3-27) as part of routine outcome measurements. Pain and hand function were measured before treatment and 3 months after starting treatment using the Dutch version of the Michigan Hand Outcomes Questionnaire. Multivariable linear regression analysis was used to assess the influence of outcome expectations and illness perceptions on pain and hand function.

RESULTS

Both positive outcome expectations (B = 0.64; 95% CI [0.1-1.2]) and a better illness understanding (an illness perception subdomain; B = 1.53; 95% CI [0.2-2.9]) at baseline were associated with less pain at 3 months. For hand function, similar estimates were found.

CONCLUSIONS

We found that positive outcome expectations and a better illness understanding, were associated with a better outcome of non-operative treatment for CMC-1 OA.IMPLICATIONS FOR REHABILITATIONNon-operative treatment can often be successful for patients with arthritis of the thumb.Outcome expectations and illness perceptions are associated with pain and hand function 3 months after non-operative treatment for thumb base osteoarthritis.Improving the outcome expectations and illness perceptions of patients through better education could improve the outcome of non-operative treatment.

Predictors of two-year patient satisfaction following elective knee surgery

BACKGROUND

Patient satisfaction metrics are increasingly being utilized as tools to evaluate the quality of healthcare and affect reimbursements. The objectives of this study were to (1) identify factors associated with two-year patient satisfaction after elective knee surgery, (2) compare the Surgical Satisfaction Questionnaire-8 (SSQ-8) and a numeric satisfaction scale (NSS), and (3) determine if two-year patient satisfaction can be predicted based on preoperative factors.

METHODS

A total of 365 patients undergoing elective knee surgery at a single center were administered questionnaires to assess demographics, medical history, and various patient-reported outcomes preoperatively and at two years postoperatively. Patient satisfaction was measured at two years postoperatively with SSQ-8 and NSS. Bivariate and multivariate statistical analyses were performed to identify significant associations and independent predictors of satisfaction.

RESULTS

SSQ-8 and NSS scores were significantly correlated (r_s = 0.68, P < 0.0001). Lower SSQ-8 and NSS scores were associated with black race, higher BMI, more comorbidities, unemployment, smoking, higher ASA score, and greater Met Expectations (P < 0.05). Better scores on patient-based outcome measures and better improvement from baseline were significantly correlated with higher satisfaction on both SSQ-8 and NSS. Multivariable analysis identified greater Met Expectations and higher two-year Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores as independent predictors of greater SSQ-8 scores (adjusted r² = .52). Greater Met Expectations and better two-year PROMIS Social Satisfaction scores were independent predictors of NSS score (adjusted r² = .41). In contrast, when only preoperative variables were considered, the multivariable regression model accounted for only 14% of the variance in SSQ-8 and 6% of the variance in NSS.

CONCLUSION

While there are multiple preoperative factors that are associated with two-year patient satisfaction after knee surgery, those factors contribute relatively little to satisfaction. Meeting expectations and better patient-based outcomes at two years are more important.

Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients

Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

Expected Versus Experienced Health-Related Quality of Life Among Patients Recovering From Cancer Surgery: A Prospective Cohort Study

Patient expectations of the impact of surgery on postoperative health-related quality of life (HRQL) may reflect the effectiveness of patient-provider communication. We sought to compare expected versus experienced HRQL among patients undergoing cancer surgery.

METHODS

Adults undergoing cancer surgery were eligible for inclusion (2017-2019). Preoperatively, patients completed a smartphone-based survey assessing expectations for HRQL 1 week and 1, 3, and 6 months postoperatively based on the 8 short-form 36 (SF36) domains (physical functioning, physical role limitations, pain, general health, vitality, social functioning, emotional role limitations, and mental health). Experienced HRQL was then assessed through smartphone-based SF36 surveys 1, 3, and 6 months postoperatively. Correlations between 1- and 6-month trends in expected versus experienced HRQL were determined.

RESULTS

Among 101 consenting patients, 74 completed preoperative expectations and SF36 surveys (73%). The mean age was 54 years (SD 14), 49 (66%) were female, and the most common operations were for breast (34%) and abdominal (31%) tumors. Patients expected HRQL to worsen 1 week after surgery and improve toward minimal disability over 6 months. There was poor correlation (≤±0.4) between 1- and 6-month trends in expected versus experienced HRQL in all SF36 domains except for moderate correlation in physical functioning (0.50, 95% confidence interval [0.22-0.78], P < 0.001) and physical role limitations (0.41, 95% confidence interval [0.05-0.77], P = 0.024). Patients expected better HRQL than they experienced.

CONCLUSIONS

Preoperative expectations of postoperative HRQL correlated poorly with lived experiences except in physical health domains. Surgeons should evaluate factors which inform expectations around physical and psychosocial health and use these data to enhance shared decision-making.

The Effect of Photographic Visual Aids in Preoperative Patient Counseling in Oculoplastic Surgery

PURPOSE

To investigate the effect of visual supplementation and its mode of delivery in preoperative counseling of patients undergoing oculoplastic surgery.

METHODS

A prospective randomized controlled trial of consecutive patients undergoing oculoplastic eyebrow and eyelid surgery was conducted. Patients were randomized to an "oral only" group receiving routine preoperative oral counseling or an "oral and visual" group receiving identical counseling visually supplemented with photographs demonstrating common postoperative physical findings. Patients in the "oral and visual" group were further randomized to receive education from the medical team in person versus prerecorded video. Patient emotions and expectations regarding postoperative healing were assessed preoperatively and at 1 week and 2 months postoperatively.

RESULTS

103 patients were included: 32 received in-person oral education, 33 received in-person oral education with photographs, and 38 received education with photographs via video. There were no significant differences in demographics or preoperative patient fear, anxiety, or preparedness. The "oral and visual" group expected more severe postsurgical discomfort and physical findings at postoperative day 1 and week 1. There were no significant differences between groups in surgery signup, cancellation, or triage call rates; patient expectations of postoperative months 2 and 4; or in anxiety, preparedness, or satisfaction.

CONCLUSIONS

Visual supplementation in preoperative counseling increases patient expectations of postoperative physical findings without escalating fear or anxiety, and has no significant impact on patient emotions, triage call rates, and satisfaction throughout their surgical experience. Preoperative education via video is perceived by patients to be equivalent to counseling in person by the surgeon.

Effect of pre-treatment expectations on post-treatment expectation fulfillment or outcomes in patients with distal radius fracture

BACKGROUND

The influence of patient expectations on patient-rated outcomes (PRO) after elective orthopedic procedures has been addressed in previous studies. However, the influence of pre-treatment expectations on post-treatment PRO was rarely examined in patients with extremity fractures.

PURPOSE

The purpose of this study was to determine if pre-treatment expectations have an effect on post-treatment expectation fulfillment or PRO in patients surgically and conservatively managed for distal radius fractures (DRFs).

STUDY DESIGN

Prospective cohort study METHODS: For this study, 114 consecutive patients treated for DRF between January 2017 and February 2018 were enrolled. Of the 114 patients, 81 underwent surgical treatment (surgical group), and 33 were managed conservatively (conservative group). All patients completed a 7-item pre-treatment expectation questionnaire initially. There were 66 patients in the surgical group and 25 patients in the conservative group available at the 1-year follow-up and completed a 6-item post-treatment expectation fulfillment questionnaire and patient-reported wrist evaluation (PRWE) questionnaire.

RESULTS

The surgical group showed a significantly higher median pre-treatment expectation score than the conservative group. However, no significant differences in post-treatment expectation fulfillment scores and PRWE scores were observed between groups. Higher pre-treatment expectation score was moderately correlated with higher post-treatment expectation fulfillment score (r = 0.36, P = 0.003) and lower PRWE score (r = -0.3, P = 0.02) in the surgical group. However, the pre-treatment expectation score was not significantly correlated with the post-treatment expectation fulfillment score (r = -0.09, P = 0.65) or PRWE score (r = -0.02, P = 0.93) in conservative group. In the surgical group, multivariable linear regression analysis showed that post-treatment expectation fulfilment score could be explained by the pre-treatment expectation score (Beta = 0.41, P = 0.001), accounting for 15% of the variance, and PRWE score was also explained by the pre-treatment expectation score (Beta = 0.39, P = 0.001), accounting for 14% of the variance.

CONCLUSIONS

In conclusion, higher pre-treatment expectation score was moderately correlated with higher the post-treatment expectation fulfillment score and lower PRWE score, and the pre-treatment expectation score could only explain a small amount of variance seen in the post-treatment expectation fulfillment and PRWE scores in the surgical group. However, there was no association between the pre-treatment expectation score and the post-treatment expectation fulfillment score or the PRWE score in the conservative group.

Patient Mindset and the Success of Carpal Tunnel Release

BACKGROUND

Depression and pain catastrophizing are aspects of the patient's mindset that have been shown to be important in relation to the outcome of carpal tunnel release. However, other factors of the patient's mindset have been understudied, such as treatment expectations and illness perceptions. The aim of the present study was to investigate the influence of these mindset aspects on outcome of carpal tunnel release, in addition to psychological distress and pain catastrophizing.

METHODS

A total of 307 patients with carpal tunnel syndrome who visited outpatient hand surgery clinics and who completed online questionnaires regarding demographic and psychosocial characteristics and carpal tunnel syndrome severity were included. The patient mindset was measured with the Patient Health Questionnaire-4, the Pain Catastrophizing Scale, the Credibility Expectancy Questionnaire, and the Brief Illness Perception Questionnaire. Hierarchical linear regression models were used to examine the relation between self-reported severity 6 months after carpal tunnel release, as measured with the Boston Carpal Tunnel Questionnaire, and psychosocial aspects of mindset, adjusting for preoperative Boston Carpal Tunnel Questionnaire score, patient characteristics, and comorbidities.

RESULTS

Independent associations with better self-reported outcome were found for higher treatment expectations (β = -0.202; p < 0.001) and illness comprehensibility (β = -0.223; p < 0.001). The additional explained variance in Boston Carpal Tunnel Questionnaire scores by the patient's mindset was 13.2 percent (psychological distress and pain catastrophizing together, 2.1 percent; treatment expectations and illness perceptions together, 11.1 percent).

CONCLUSION

Treatment outcome expectations and comprehensibility of illness are both independently associated with the outcome of carpal tunnel release, showing the importance of these aspects of the patient's mindset for the outcome of carpal tunnel release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Factors influencing patient loyalty to outpatient medical services: an empirical analysis of the UAE's government healthcare system

Purpose

The aim of this research is to uncover issues that inhibit patients' satisfaction and loyalty and identify factors that could enhance customer retention by government hospitals in the United Arab Emirates (UAE). The mediating impact of outpatient satisfaction on service quality, word of mouth (WoM), hospital image, outpatient–physician relationship and outpatient loyalty were tested.

Design/methodology/approach

The sample data used to test the hypotheses were drawn from a pool of patients served by a government healthcare agency in Abu Dhabi. Questionnaires were provided to 418 participants using methods such as short message service, e-mail and face-to-face delivery. The data were analyzed using SmartPLS 3.3.2 software.

Findings

The results indicate that service quality, WoM and outpatient–physician relationship positively impact outpatient satisfaction and indirectly effect outpatient loyalty; that hospital image positively impacts outpatient satisfaction and loyalty and has a partially mediating effect on loyalty; that waiting time satisfaction has no effect on outpatient satisfaction and no moderating effect on the outpatient satisfaction–loyalty relationship and that switching cost has a positive effect on loyalty but no moderating effect on the outpatient satisfaction–loyalty relationship.

Research limitations/implications

The first limitation of this study concerns the fact that only patients who had previously been served by these hospitals' outpatient units were included. Furthermore, the research was not able to obtain extensive findings related to the various factors that negatively impacted patient satisfaction and loyalty among all of the departments of government hospitals, such as inpatient care and emergency care.

Practical implications

Centered on the findings from this research, increasing switching costs would prevent patients from switching to other healthcare providers. Therefore, it has the potential to create a false loyalty or a hostage customer (Jones and Sasser, 1995). Additionally, making patients feel connected to their treatment plan and engaged in their care by developing a tool to maintain their enthusiasm about their health is important. It is therefore recommended that government hospital care providers and management consider providing online tools that patients can use to self-manage their care.

Social implications

The results regarding patients' satisfaction level suggest several areas for improvement. The first pertains to waiting area entertainment and comfort because patients indicated that there is not enough entertainment or ways to pass the time when waiting for services. In addition to enhancing the entertainment and comfort of waiting areas, government hospital staff should maintain contact with patients who are waiting to ensure that they are aware of the time they will spend. Another area for improvement is the parking lot. During summer, patients prefer to walk less in the sun, which causes them to seek parking closer to the door. Government hospital management should consider different methods for transporting patients closer to the door, such as golf carts or valet services.

Originality/value

This is the first study to investigate the mediating impact of outpatients' satisfaction between its antecedents and loyalty in the UAE. These results provide an improved understanding of the factors influencing patient choices and establish more accurate methods for increasing patient loyalty to retain more patients.

Characteristics of Patients Seeking and Proceeding with Non-Surgical Facial Aesthetic Procedures

Purpose

Identifying predictors for patients' readiness to receive non-surgical facial aesthetic treatments facilitates the physician's understanding of the patient's goals and expectations. This paper aims to identify clinical and demographic characteristics of patients who proceed with non-surgical facial aesthetic procedures in Singapore.

Patients and Methods

Using data from electronic patient health records, authors examined clinical and demographic characteristics of 624 Asian and Caucasian patients who sought treatment in a 12-month period and who had minimum follow-up of 1 year. Variables examined included age, race/ethnicity, gender, prior treatment, and attitudes and motivation for seeking treatment. Univariate and multivariate analyses of factors associated with proceeding with the treatment plan were evaluated using chi-square and logistic regression analyses.

Results

Approximately 88% of patients who sought consultation proceeded with treatment. The majority were older than 40 years of age, were female and received prior treatments. Notable is the high frequency of rejuvenation rather than correction as the clinical outcome goal. There were slightly more Caucasians than Chinese patients but the racial distribution allowed the identification of differences between the two groups. Chinese patients were younger and more likely to seek correction or more obvious changes as compared to Caucasian patients. On multivariate analyses, powerful predictors for proceeding with non-invasive facial treatments included a treatment goal of rejuvenation rather than correction, an expectation of an immediate result, and prior aesthetic treatments.

Conclusion

This study is the first to compare race/ethnic differences in factors that influence treatment with non-invasive aesthetic procedures. This is also the first to identify demographic, clinical and motivational characteristics associated with actual treatment with non-invasive facial procedures. Further research on a systematic approach to defining a patient's motivation for receiving treatment, as well as research identifying which patients are more likely to have positive clinical outcomes are warranted.

The virtue of optimistic realism - expectation fulfillment predicts patient-rated global effectiveness of total hip arthroplasty

BACKGROUND

Emerging evidence highlights the importance of preoperative expectations in predicting patient-reported outcomes of orthopedic surgeries. To date, it is still a matter of controversy whether patient satisfaction can be maximized by promoting either optimistic or realistic outcome expectations before surgery. Adjusting overly optimistic outcome expectancies in favor of a more realistic outlook on the limitations of total hip arthroplasty could reduce the risk of disappointment and lead to greater satisfaction with surgery outcomes. Our prospective cohort study was aimed at comparing the relative predictive influence of baseline expectations, expectation fulfillment and symptomatic improvement on the global effectiveness of total hip arthroplasty.

METHODS

Ninety patients (49 female, 41 male; mean age: 63 ± 12.87 years) fulfilled inclusion criteria and completed a comprehensive preoperative assessment comprising sociodemographic, clinical, functional and psychological phenotypes. Moreover, the strengths of preoperative expectations for improvements in eight pain-related and functional domains were recorded on a 5-point Likert-scale. At 12 months after surgery, patients were asked to rate perceived improvements in each of these domains as well as the global effectiveness of the total hip replacement on a 5-point Likert-scale. To evaluate the relative impact of preoperative expectations, symptom improvement and the fulfillment of expectations on the global effectiveness of surgery, a sequential multiple regression analysis was performed.

RESULTS

Compared with the actual improvement at 12-months follow-up, prior expectations had been overly optimistic in about 28% of patients for hip pain, in about 45% for walking ability and around 60% for back pain, independence in everyday life, physical exercise, general function social interactions and mental well-being. An optimistic hip pain expectation, walking ability at baseline and the fulfillment of expectations for walking ability, general function and independence in everyday life were found to independently predict global effectiveness ratings.

CONCLUSIONS

Positive expectation about pain and the fulfillment of expectations concerning functional domains predicted higher global effectiveness ratings. In line with many authors investigating the relationship between the fulfillment of expectations and satisfaction with medical interventions, we suggest that professionals should explicitly address their patients' expectations during the preoperative education and consultation.

Role of Preoperative Patient Expectations in Adult Cochlear Implant Outcomes

OBJECTIVE

Preoperative expectations affect patient outcomes in many health conditions, but expectations are rarely assessed in adult cochlear implant (CI) users. This study is a first step in assessing the contribution of preoperative expectations to postoperative CI outcomes, including speech recognition, CI quality of life (CIQOL), and CI satisfaction.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary medical center.

PATIENTS

Fourty one adult CI patients.

INTERVENTIONS/MAIN OUTCOME MEASURES

Preoperative expectation questionnaire results, pre- and postoperative speech recognition (CNC and AzBio) scores, postoperative CIQOL domain scores and global scores, and CI satisfaction scores using a visual analog scale (VAS). Cohen's d was used to express effect size.

RESULTS

Overall, patients with lower preoperative CI performance expectations showed higher postoperative QOL. This effect was large for the emotional, entertainment, and social domains (d = 0.85-1.02) of the CIQOL-35 and medium for the communication, listening effort domains, and the Global score (d = 0.55-0.63). Preoperative performance expectations showed minimal associations with preoperative versus postoperative change in CNC (d = -0.26; -0.69-0.18) or AzBio scores (d = -0.28; -0.72-0.15). Determining the extent to which preoperative expectations played a role in postoperative satisfaction with CIs was limited by the clustering of satisfaction scores in the upper range of the scale (VAS mean 81.1).

CONCLUSIONS

This study provides preliminary evidence that patients' expectations before cochlear implantation may influence their postoperative quality of life and other outcomes, but not postoperative speech recognition. This suggests that an increased emphasis should be placed on measuring and counseling expectations in CI candidates. This assumption needs to be confirmed with additional research with larger sample sizes, more sensitive satisfaction measures, and a prospective design.

Examining Preoperative Expectations and Postoperative Satisfaction in Rhinoplasty Patients: A Single-Center Study

Background: In Rhinoplasty, understanding patient expectations are pivotal in achieving an optimal surgical outcome. Objective: To understand preoperative expectations and postoperative satisfaction in patients undergoing rhinoplasty for functional, aesthetic, or both. Method: Adult patients undergoing functional, aesthetic, or combined rhinoplasty from March 2017 to June 2019 were prospectively enrolled. Only patients with complete preoperative functional and cosmetic expectation visual analog scales (VAS) and at least one postoperative functional and cosmetic satisfaction VAS were included. Nasal Obstruction and Symptom Evaluation Scale score and Standardized Cosmesis and Health Nasal Outcomes Survey score were also collected. Results: In the functional subgroup (mean preoperative functional expectation VAS score [17.98 (22.49)] higher mean (standard deviation) postoperative functional satisfaction VAS score were observed at postoperative time interval <2 months [29.59 (27.08), p = 0.008] and 8-12 months [31.43 (28.25), p = 0.035]. In the aesthetic subgroup mean preoperative cosmetic expectation VAS score [89.69 (17.74)], lower mean postoperative aesthetic satisfaction VAS scores were observed at <2 months [79.09 (20.01), p = 0.0001], 2-5 months [79.79 (20.79), p = 0.032], 5-8 months [72 (18.27), p < 0.0001], 8-12 months [78.15 (24.50), p = 0.021], and >12 months [75 (20.64), p = 0.00020]. In the combined subgroup (mean preoperative aesthetic expectation VAS score [85.85 (18.19)]), lower mean postoperative aesthetic satisfaction VAS scores were observed at 2-5 months [78.94 (20.88), p = 0.01] and at >12 months [75.86 (25.57), p = 0.01]. Conclusion: Although rhinoplasty patients tend to be less satisfied with aesthetic than the functional outcome of surgery, preoperative aesthetic expectations are higher in cosmetic rhinoplasty and functional and cosmetic rhinoplasty patients.

ThyroidEx: Development and Preliminary Validation of a Thyroid Surgery Expectations Measure

OBJECTIVE

To address the lack of validated patient-reported outcome (PRO) instruments that define and quantify patient expectations in thyroid cancer surgery, we developed and initially validated ThyroidEx, a novel disease-specific PRO instrument.

STUDY DESIGN

Survey study.

SETTING

Single-institution tertiary care cancer center.

METHODS

An expert panel drafted an initial set of thyroid cancer-specific concepts, which was used in semistructured concept elicitation interviews with patients with thyroid cancer 4 weeks before and 8 weeks after surgery. Candidate items were generated per patient responses and refined via cognitive interviewing and additional review by the expert panel. The draft ThyroidEx was then preoperatively administered to a separate cohort undergoing thyroid cancer surgery to establish a final item set and initial psychometric evidence.

RESULTS

Prospective concept elicitation interviews generated 358 patient-elicited concepts (n = 15 patients). These were then placed into 70 unique subcategories from which 41 items were generated for cognitive interviews with 20 patients preoperatively and 28 postoperatively. After expert panel review, ThyroidEx included 18 items across 2 scales (Expectations and Concerns), with an additional item about beliefs. In the preoperative cohort in phase 2 (n = 67), internal consistency Cronbach's α values ranged from 0.81 to 0.89. Descriptive analysis showed significant differences between patients' concerns and expectations and clinicians' perceptions.

CONCLUSION

Defining expectations represents an important modifier in the measurement of PROs. Preliminary validation of ThyroidEx revealed incongruent expectations between expert opinion and patients. Future development and implementation of ThyroidEx may affect preoperative consultation and the consent process.

Aortic valve replacement: validation of the Toronto Aortic Stenosis Quality of Life Questionnaire

Aims

There is no quality of life tool specifically developed for patients with severe aortic stenosis (AS) to assess how this chronic condition and its treatment affect patients. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) has been developed to overcome this gap. The results of the validation of the TASQ in patients undergoing treatment for severe AS are presented.

Methods and results

Prospective study at 10 centres in Europe and Canada, which enrolled 274 patients with severe symptomatic AS undergoing surgical or transcatheter aortic valve replacement. Mean TASQ score at baseline was 71.2 points and increased to 88.9 three months after aortic valve implantation (P < 0.001). Increases were seen for the emotional impact (32.0 to 39.0; P < 0.001), physical limitations (14.8 to 22.0; P < 0.001), and physical symptoms (8.5 vs. 11.0; P < 0.001) domains. Internal consistency was good/excellent for overall TASQ score (α = 0.891) and for the physical limitation, emotional impact, and social limitation domains (α = 0.815–0.950). Test–retest reliability was excellent or strong for the overall TASQ (intraclass correlation coefficient of 0.883) and for the physical symptoms, physical limitation, emotional impact, and social limitation domains (intraclass correlation coefficient of 0.791–0.895). Responsiveness was medium overall (Cohen's d = 0.637) and medium/large for physical symptoms, emotional impact, and physical limitations (0.661–0.812). Sensitivity to change was significant for physical symptoms, physical limitations (both P < 0.001), emotional impact (P = 0.003), and social limitations (P = 0.038).

Conclusions

The TASQ is a new, brief, self‐administered, and clinically relevant health‐specific tool to measure changes in quality of life in patients with AS undergoing an intervention.

Failure to Cure in Patients Undergoing Surgery for Esophageal Carcinoma: Hospital of Surgery Influences Prospects for Cure: A Nation-wide Cohort Study

OBJECTIVE

This study aimed to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy.

SUMMARY BACKGROUND DATA

Failure to cure is a composite outcome measure that could be used for hospital comparison in esophageal carcinoma care.

METHODS

All patients registered in the Dutch Upper GI Cancer Audit who underwent potentially curative esophageal carcinoma surgery in 2011 to 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no surgical resection due to intraoperative metastasis or locally irresectable tumor, 2) macroscopically or microscopically incomplete resection, or 3) 30-day/in-hospital mortality. Association of baseline characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage patients.

RESULTS

Some 5894 patients from 22 hospitals were included, of whom 630 (10.7%) had failure to cure (hospital variation [5.5%-19.1%]). Higher age, preoperative weight loss, higher ASA-score, higher N-stage, neoadjuvant chemotherapy, or no neoadjuvant therapy (compared with neoadjuvant chemoradiotherapy), open surgery, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant higher failure to cure percentages, whereas 2 had lower percentages. Of 151 salvage esophagectomy patients, 32.5% had failure to cure. The failure to cure rate after salvage surgery was 27.6% in high-volume hospitals and 47.6% in medium-volume hospitals.

CONCLUSIONS

The incidence of failure to cure was 10.7%. Given the significant hospital variation in the percentage of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this procedure is warranted.

The Power of Patient Norms: Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction

INTRODUCTION

Enhanced recovery after surgery pathways designed to optimize postoperative care have become increasingly popular across multiple surgical specialties with proven benefits. In this retrospective cohort study, we present a comparative evaluation of the impact of protocol-based postoperative care on free autologous breast reconstruction patients.

METHODS

With institutional review board approval, we performed a chart review of patients who underwent breast reconstruction with free autologous tissue transfer by a single surgeon from 2006 to 2017. Patients were managed according to a postoperative protocol since 2006 that initially called for discharge home on postoperative day (POD) 4 for unilateral cases and POD 5 for bilateral cases. In May 2015, the protocol was revised to discharge home on POD 3 for all cases. Patients who underwent reconstruction before (2006 to April 2015) and after (May 2015 to 2017) the change in postoperative protocol were compared.

RESULTS

A total of 432 patients (647 breasts) underwent free autologous breast reconstruction during the study period. Flaps were predominantly muscle-sparing transverse rectus abdominis myocutaneous (56.3%) or deep inferior epigastric perforator (30.3%) flaps. Average patient age was 51.6 years (range, 29.7-80.3 years). Unilateral reconstructions were performed for 167 patients before and 50 patients after the protocol change; average hospital length of stay (LOS) was 4.5 and 3.4 days, respectively (P < 0.001). Bilateral reconstructions were performed for 153 patients before and 62 patients after the protocol change; average hospital LOS was 5.1 and 3.5 days, respectively (P < 0.001). There was no significant increase in patients with major or minor complications.

CONCLUSIONS

Revising our postoperative protocol to reduce expected LOS was associated with an overall faster time to discharge without negative consequences in patients who underwent unilateral and bilateral free autologous breast reconstruction. Use of protocols to guide behavior not only can improve the patient experience by promoting a quicker return home, but may also have the added benefit of decreasing healthcare expenditures through reduced inpatient utilization.

Communication in surgical decision-making while managing metastatic bone disease: matching patient expectations with surgical goals

BACKGROUND

There is a paucity of research examining how surgical decision-making for metastatic bone disease (MBD) can be optimized to improve quality of life (QOL) and functional outcomes, while accurately aligning with patient goals and expectations. The objective of this study was to survey and interview patients with MBD and support persons (PS), physicians, and allied health care providers (HCP) with the goal of identifying (1) important surgical issues related to MBD management, (2) discordance in perioperative expectations, and (3) perceived measures of success in the surgical management of MBD.

METHODS

Utilizing a custom survey developed by HCP and patients with MBD, participants were asked to (1) identify important issues related to MBD management, (2) rank perceived measures of success, and (3) answer open-ended questions pertaining to the management of MBD.

RESULTS

From the survey, increased life expectancy, minimizing disease progression, removal of local tumour, timely surgery after diagnosis, increased length of hospitalization, and physiotherapy access were all identified as significant discordant goals between PS and physicians/HCP. Conversely, there was an agreement between physicians and HCP who considered improved QOL and functional outcomes as most important goals. Structured homogenous-group workshops identified the need for (1) improved discussions of prognosis, surgical options, expectations, timelines, and resources, (2) the use of a care team "quarterback", and (3) an increased use of multi-disciplinary treatment planning.

CONCLUSIONS

We feel this data highlights the importance of improved communication and coordination in treating patients with MBD. Further research evaluating how surgical techniques influence survival and disease progression in MBD is highly relevant and important to patients.

Patients undergoing shoulder surgery have high preoperative expectations

PURPOSE

The primary aims of this study were to (1) assess the preoperative expectations of patients undergoing shoulder surgery, and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. It was hypothesized that younger patients with worse function and worse health status had higher expectations of shoulder surgery.

METHODS

Data from a total of 319 patients (319 shoulders) from 2015-2018 were analyzed. Patients completed a series of questionnaires covering demographics and patient-reported outcome measures. Expectations of treatment were evaluated using the Musculoskeletal Outcomes Data Evaluation and Management System. Bivariate analyses were performed to determine the significance of identified associations.

RESULTS

The study population consisted of 186 males and 133 females. The mean age was 46.9 (± 17.2), and the mean BMI was 30.1 (± 6.8). Overall, patients had high expectations of shoulder surgery, with a mean score of 84.7 (± 19.3). The most commonly performed procedure in the study population was arthroscopic rotator cuff repair. There was a significant association between pre-treatment expectations and ethnicity, previous shoulder surgery, employment status, income level, tobacco use, preoperative opioid use, depression, and ASA score.

CONCLUSION

The findings suggest that patients undergoing shoulder surgery have high overall preoperative expectations, which were significantly associated with ethnicity, surgical history, opioid use, and employment status, and with multiple patient-reported outcome measures including physical function, pain interference, fatigue, and depression. Nevertheless, by discussing expectations preoperatively, orthopaedic surgeons can help patients develop high but realistic expectations to improve outcomes and satisfaction.

LEVEL OF EVIDENCE

IV.

What the thyroid cancer patient wants to know: ThyCa survey by the American Head and Neck Society Endocrine Surgery Section

OBJECTIVE

To survey a large cohort of thyroid cancer survivors from ThyCa on information needs and expectations of their treatment to better understand the pretreatment counseling, information, and support needs of this population.

METHODS

Anonymous survey of thyroid cancer survivors.

RESULTS

One thousand one hundred twenty-four patients with thyroid cancer participated in the survey. Three hundred sixty-two (37.44%) reported not having had a full understanding of their treatment plan and 407 (46.41%) reported that their thyroid cancer treatment did not conform to expectations. Patients diagnosed at younger ages were significantly more likely to report inadequate understanding of the treatment, failure of treatment to meet expectations, and call for greater attention to psychological well-being. Older patients were more likely to report unexpected effects on speech and swallowing. Regardless of age, patients most frequently called for greater attention to management of energy levels (endorsed by 61% of respondents), psychological well-being (50%), and weight changes (48%).

CONCLUSIONS

Improvements are needed in age-specific communication of thyroid cancer diagnosis and treatment.

Smaller Inguinal Hernias are Independent Risk Factors for Developing Chronic Postoperative Inguinal Pain (CPIP): A Registry-based Multivariable Analysis of 57, 999 Patients

OBJECTIVE

Impact of inguinal hernia defect size as stratified by the European Hernia Society (EHS) classification I to III on the rate of chronic postoperative inguinal pain (CPIP).

BACKGROUND

CPIP is the most important complication after inguinal hernia repair. The impact of hernia defect size according to the EHS classification on CPIP is unknown.

METHODS

In total, 57,999 male patients from the Herniamed registry undergoing primary unilateral inguinal hernia repair including a 1-year follow-up were selected between September 1, 2009 and November 30, 2016. Using multivariable analysis, the impact of EHS inguinal hernia classification (EHS I vs EHS II vs EHS III and/or scrotal) on developing CPIP was investigated.

RESULTS

Multivariable analysis revealed for smaller inguinal hernias a significant higher rate of pain at rest [EHS I vs EHS II: odds ratio, OR = 1.350 (1.180-1.543), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 1.839 (1.504-2.249), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.363 (1.125-1.650), P = 0.002], pain on exertion [EHS I vs EHS II: OR = 1.342 (1.223-1.473), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.002 (1.727-2.321), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.492 (1.296; 1.717), P < 0.001], and pain requiring treatment [EHS I vs EHS II: OR = 1.594 (1.357-1.874), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.254 (1.774-2.865), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.414 (1.121-1.783), P = 0.003] at 1-year follow-up. Younger patients (<55 y) revealed higher rates of pain at rest, pain on exertion, and pain requiring treatment (each P < 0.001) with a significantly trend toward higher rates of pain in smaller hernias.

CONCLUSIONS

Smaller inguinal hernias have been identified as an independent patient-related risk factor for developing CPIP.

The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders

OBJECTIVE

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment.

METHODS

Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status).

RESULTS

While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3).

CONCLUSIONS

Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

Impact of Preoperative Video Education for Cataract Surgery on Patient Learning Outcomes

Purpose

To assess the effect of an educational video on 1) patient knowledge about cataract surgery, 2) patient perception of preoperative assessment visit quality, 3) face-to-face time with the surgeon, and 4) choices regarding premium intraocular lenses (IOLs) or laser-assisted cataract surgery (LACS).

Setting

Eye clinic in an academic medical center.

Design

Prospective survey of patients who randomly viewed or did not view an educational video.

Methods

Patients of three cataract surgeons completed a survey during cataract surgery preoperative visits. One group viewed an educational video about cataract surgery, while the other did not. All patients received their surgeon’s typical preoperative counseling.

Results

A total of 101 patients were surveyed. Out of 101 patients, 58 viewed the educational video. Patients who viewed the video exhibited stronger learning outcomes; in particular, patients who viewed the video scored higher on cataract surgery educational assessments than those who did not (83% vs 76%, p=0.032), particularly on the assessment of postoperative visual expectations (98% vs 80%, p=0.003). Differences in educational assessment scores between groups were not affected by which surgeon patients saw (p=0.807). Patients who watched the video were more likely to agree their surgeon provided quality explanations (93% vs 74% strongly agreed, p=0.025) and trended toward greater perception the surgeon spent enough time with them (p=0.067). Video education did not affect face-to-face surgeon time with patients (p=0.212) or choices of multifocal IOLs (p=0.795), toric IOLs (p=0.321), or LACS (p=0.940).

Conclusion

Video education during preoperative cataract surgery assessments improved patient understanding of cataract surgery and perception of preoperative visits. Video education is easily integrated into preoperative visits and can enhance the preoperative experience.

What Outcomes Matter to Patients After Joint or Spine Surgery?

Purpose

Patient-reported outcome measures (PROMs) are increasingly used in clinical care, but there have been few studies of what patients identify as the most important outcomes.

Methods

Semi-structured interviews were conducted with 65 patients undergoing hip or knee replacement, spinal discectomy/laminotomy, or a spinal fusion. Interviews focused on outcomes patients identified as important, perceived usefulness of standardized PROMs measures, and contextual situations important to their care. Data were analyzed using a directed content analysis approach.

Results

Patients identified desired outcomes that were unique and important to them. Their preferred outcomes focused in the areas of freedom from pain, getting back to their normal life, and returning to an active lifestyle. Patients cared more about their individual preferred outcomes, which had more meaning for them, than a standardized PROM score. Patients also identified particular contextual situations that their care team was assumed to know about but that may not have been known.

Conclusions

Patients identify specific preferred outcomes from these surgical procedures that are important and meaningful to them and that frame whether they see their surgery as a success. They also identified personal factors that they assume their surgeons know about, which affect their care and recovery. These findings underscore the importance of engaging patients in discussions about their preferences and contextual factors both prior to and after surgery.

Substance use disorder patients’ expectations on transition from treatment to post-discharge period

Aim:

There is limited knowledge about how inpatients anticipate factors that facilitate the transition between specialised inpatient treatment for substance use disorder (SUD) and the post-discharge period. This study explores factors that inpatients anticipated would facilitate such a transition period.

Method:

A focus group study, consisting of four group interviews with individuals in inpatient SUD treatment, was conducted to explore their expectations for the transition and post-discharge period ahead of them. The transcribed interview material was analysed using thematic analysis.

Findings:

The analytical process led to three themes: “Belonging”, “Intrapersonal processes” and “Predictability”. Correspondence between inpatients’ expectations and the services they are offered in the transition and post-discharge period may serve as proper support for inpatients ahead of a vulnerable phase, such as the transition and post-discharge period.

Conclusions:

Findings from the current study highlight overarching elements that inpatients envisioned to be facilitating, such as social support, motivation, self-efficacy, self-awareness and predictability in basic elements such as employment, housing and personal finances. Findings from this study and previous ones imply that certain factors appear to facilitate in vulnerable phases, such as service level transitions. These facilitating factors should be taken into consideration and used as steppingstones through the transition and post-discharge period after inpatient SUD treatment.

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery

OBJECTIVE

To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary referral medical center.

SUBJECTS AND METHODS

We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7.

RESULTS

A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3.

CONCLUSION

Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.

Is Single-Puncture TMJ Arthrocentesis Superior to the Double-Puncture Technique for the Improvement of Outcomes in Patients With TMDs?

PURPOSE

Arthrocentesis is a common treatment for temporomandibular joint disorders. Although modifications of the standard double-puncture technique have been described, no consensus has been reached regarding which is the best. The aim of the present study was to compare the outcomes of the single- and double-puncture arthrocentesis techniques (SPT and DPT, respectively).

MATERIALS AND METHODS

A systematic review following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. Two independent reviewers conducted electronic searches in the MEDLINE/PubMed, Cochrane Library, and Scopus databases for relevant studies reported up to January 2019. Studies comparing type I SPT (only 1 cannula) or type II SPT (2 soldered cannulas) to conventional DPT were considered. Data regarding the maximal mouth opening (MMO), joint pain, and operative time were extracted for the meta-analysis. In the case of statistically significant heterogeneity (P < .10), a random effects model was used to assess the significance of the treatment effects. Otherwise, a fixed effects model was used. The included randomized controlled trials (RCTs) were assessed for methodologic quality using the Cochrane Collaboration tool.

RESULTS

Nine studies were included for qualitative synthesis. Two were suitable for quantitative synthesis per outcome. The meta-analysis did not find any differences between SPT and DPT in relation to the MMO. However, in relation to joint pain, the results slightly favored the use of DPT. No differences in operative time were found between type I SPT and DPT (P = .49).

CONCLUSIONS

The present study found no differences between the SPT and DPT in relation to the MMO, and no difference was found in operative time between the DPT and type I SPT. Because of the heterogeneity between studies, it might be interesting to conduct more homogeneous RCTs to elucidate which technique results in better clinical outcomes.

Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients

End-stage osteoarthritis is commonly treated with joint replacement. Despite high clinical success rates, up to 28% of patients are dissatisfied with the outcome.

This best-evidence synthesis aimed to review studies with different forms of study design and methodology that examined the relationship between (fulfilment of) outcome expectations of hip and knee patients and satisfaction with outcome.

A literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane, and Google Scholar to identify studies conducted up to November 2017. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale.

In this best-evidence synthesis systematic review, the following main results could be seen. In only half of all studies were preoperative expectations associated with level of satisfaction, while in almost all studies (93%), fulfilment of expectations was related to satisfaction. The effect of met expectations did not differ between hip and knee patients or study design.

Fulfilment of expectations seems to be consistently associated with patient satisfaction with outcome. Emphasis in future research must be placed on the operationalization and measurement of expectations and satisfaction to determine the (strength of the) influence of these different forms of assessment on the (existence of the) relationship.

Cite this article: EFORT Open Rev 2020;5:226-240. DOI: 10.1302/2058-5241.5.190015

Comparison of Accuracy of Patient and Physician Scar Length Estimates Before Mohs Micrographic Surgery for Facial Skin Cancers

IMPORTANCE

Patients are satisfied when surgical outcomes meet their expectations. Dissatisfaction with surgical scars is one of the most common reasons that patients sue surgeons who perform Mohs micrographic surgery (MMS).

OBJECTIVE

To measure the accuracy of patient and physician estimations of scar length prior to skin cancer removal with MMS.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted between December 1, 2017, and February 28, 2018, at the MMS clinic of a single tertiary referral center health system. A total of 101 adults presenting for MMS for treatment of facial skin cancers volunteered for this study, and 86 surgeons who performed the MMS procedure participated.

MAIN OUTCOMES AND MEASURES

Patients and physicians independently drew the anticipated scar length on the patients' skin prior to surgery. Preoperative estimates by patients and surgeons were compared with actual postoperative scar length.

RESULTS

Of the 101 patients who participated, 57 patients (56.4%) were men and 57 patients (56.4%) were aged 65 years or older. Eighty-four patients (83.2%) underestimated scar length, whereas 67 of the 86 surgeons (77.9%) correctly estimated the scar length (P < .001). The actual postoperative scar length was 2.2 (interquartile range, 1.5-3.6) times larger than the patients' preoperative estimate but only 1.1 (interquartile range, 1.0-1.2) times larger than the surgeons' preoperative estimate (P < .001). Preoperative consultation with the surgeon, a personal history of MMS, or patient-directed research about MMS were not associated with improvement of patients' estimations of scar length.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that patients with facial skin cancers have unrealistic expectations regarding scars that measure, on average, less than half the length of the actual postoperative scars. Surgeons appear to accurately estimate the length of most surgical scars and have an opportunity to set realistic patient expectations about scar length before surgery.

Associations between perceived somatic symptoms and mental health after Roux-en-Y gastric bypass: a 3-year prospective cohort study

BACKGROUND

Attention to and interpretation of symptoms are influenced by psychologic and contextual factors. Preoperative anxiety, and to some extent depression, has been found to predict the perceived impact of somatic symptoms 1 year after Roux-en-Y gastric bypass. Postoperative changes in negative affect may possibly both influence and be influenced by the perception of somatic symptoms.

OBJECTIVES

This study aimed to explore whether preoperative anxiety and depressive symptoms correlated with perceived impact of somatic symptoms 3 years after Roux-en-Y gastric bypass. Second, we aimed to examine the 3-year trajectory of depressive and anxiety symptoms, and their interaction with perceived somatic symptoms postoperatively.

SETTING

University hospital.

METHODS

Presurgery, 1-, and 3-year postsurgery data were collected from 169 participants (62.4% follow-up). Anxiety and depressive symptoms were assessed at all time points. The participants reported the degree of perceived impact of various somatic symptoms 1 and 3 years after surgery. A cross-lagged, autoregressive regression analysis was employed to examine the mutual interaction of trajectories over the follow-up period.

RESULTS

Fatigue (30.8%) and dumping (23.7%) were common high-impact symptoms 3 years postoperatively. Higher baseline anxiety was associated with higher impact of fatigue, pain, and diarrhea, while depressive mood was related to higher impact of diarrhea at 3-year follow-up. Higher anxiety/depression symptoms were bidirectionally related to higher perceived total symptom impact at both 1 and 3 years postoperatively, controlling for percent total weight loss. Higher perceived impact of somatic symptom burden at 1 year after surgery predicted a significant increase in depressive symptoms the next 2 years.

CONCLUSION

Baseline anxiety was associated with higher perceived impact of several somatic symptoms 3 years after Roux-en-Y gastric bypass. Higher total symptom burden (pain, fatigue, dumping, diarrhea, and vomiting) at 1 year after surgery predicted increase in depression over the next 2 years. The results underscore the importance of managing somatic symptoms after surgery to prevent patients' distress.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q

PURPOSE

An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis.

METHODS

Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis.

RESULTS

Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (β = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (β = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (β = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05).

CONCLUSION

Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

Riding a Tiger: Maximizing Effects of Manual Therapies for Pelvic Pain

Manual therapy interventions are frequently used during the management of pelvic pain conditions. Pain relief after any intervention results from effects unrelated to the intervention, effects specific to the intervention, and effects of context in which the intervention is provided. Understanding these multiple mechanisms allows providers of manual therapy to maximize outcomes by deliberately harnessing each of these core elements of pain relief.

Expectations of breast-conserving therapy: a qualitative study

Background

Early-stage breast cancer is often treated with breast-conserving therapy (BCT), including lumpectomy with radiation therapy. Patients’ expectations of BCT remain largely unknown. Expectations affect perceptions of treatment-related experiences and health-related quality of life (HR-QOL) outcomes. Our primary aim was to describe expectations of BCT among patients with early breast cancer through qualitative methods. Our secondary aim was to inform preoperative patient education and improve the patient experience through knowledge.

Methods

We used a grounded-theory approach to investigate a convenience sample of 22 women with stage I and II breast cancer who were treated with BCT at a single hospital in New York City between May and August 2016. Semi-structured interviews were conducted in person and by telephone. Open-ended questions covered participants’ expectations of treatment experiences and outcomes. Data was analyzed in a line-by-line approach to identify emergent themes related to patient expectations. Interviews continued until no new themes emerged.

Results

Analysis of data identified the following themes related to patient expectations of BCT: experience of cancer care, recovery, appearance, and HR-QOL. Despite preoperative informed consent and teaching, participants expressed few expectations preoperatively, owing to a lack of knowledge about the process of care. Lack of expectations preoperatively was compensated with available care and resources postoperatively.

Conclusions

Patients in our sample had a surprisingly limited understanding of what to expect during treatment with BCT. Despite available information and preoperative teaching, patients have a clear knowledge gap regarding BCT. These findings suggest patients often undergo cancer treatment with trust rather than complete understanding of the process. This data may be used to enhance preoperative discussions aimed at preparing patients for surgery and treatment.