Development of the Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ)

Patient-centered evaluation of an expectation-focused intervention for patients undergoing heart valve surgery: a qualitative study

Objective

Randomized controlled trials demonstrate the effectiveness of expectation-focused interventions in improving recovery outcomes following cardiac surgery. For dissemination in routine health care, it is important to capture the perspective of affected individuals. This qualitative study explores the perceived benefits and intervention-specific needs of patients who received expectation-focused intervention in the context of heart valve surgery. In addition, it explores potential barriers and adverse effects.

Methods

As part of an Enhanced Recovery After Surgery (ERAS) program within a multicentered randomized controlled trial, patients undergoing minimally invasive heart valve surgery received an intervention focused on their expectations. Six weeks after the intervention, semi-structured interviews were conducted with 18 patients to assess its feasibility, acceptance, barriers, benefits, and side effects. The transcribed interviews were analyzed using qualitative content analysis.

Results

The results indicate that both the intervention and the role of the patient and psychologist are key aspects in evaluating the expectation-focused intervention. Five key themes emerged from the patients' perspective: personal needs, expectations and emotions, relationship, communication, and individuality. Patients valued the preparation for surgery and recovery and the space for emotions. Establishing a trustful relationship and addressing stigmatization were identified as primary challenges within the intervention.

Conclusion

Overall, patients experienced the expectation-focused intervention as helpful and no adverse effects were reported. Perceived benefits included enhanced personal control throughout the surgery and recovery, while the potential barrier of stigmatization towards a psychologist may complicate establishing a trustful relationship. Addressing personal needs, as a relevant topic to the patients, could be achieved through additional research to identify the specific needs of different patient subgroups. Enhancing the expectation-focused intervention could involve the implementation of a modular concept to address individual needs better.

What Really Matters to Survivors of Acute Type A Aortic Dissection-A Survey of Patient-Reported Outcomes in the Dutch National Aortic Dissection Advocacy Group

(1) Background: Type A acute aortic dissection (TAAAD) almost always requires emergency surgery, and postoperative complications are common. Quality assurance systems tend to measure only the hard outcomes, e.g., complications and mortality. Our aim was to assess the health-related quality of life of TAAAD survivors. (2) Methods: An anonymized, Dutch language, web-based survey was sent out to all of the participants of the 2022 Annual Meeting of the Dutch National Aortic Dissection (DNAD) advocacy group via their own representatives. The survey was divided into five sections: patient information, global satisfaction, surgery, including complications, and the recovery period. (3) Results: Ninety members of the DNAD group attended the meeting. Seventy-five (83%) participated in the survey, and the responses from 61 (81%) were available for analysis. Despite hindrances in their daily life (complications, changes in physical, cognitive, and social functioning), patients were satisfied with their treatment, and all would undergo the procedure again. In addition they requested better post-discharge guidance and communication (4) Conclusion: The emphasis lies in equipping patients with knowledge about potential outcomes and effective coping strategies. This underscores the importance of communication and expectation management, in line with established literature.

Understanding patient-reported knowledge of hernia surgery: a quantitative study

PURPOSE

The objective of this study was to gather information on patient-reported knowledge (PRK) in the field of hernia surgery.

METHODS

A prospective quantitative study was designed to explore different aspects of PRK and opinions regarding hernia surgery. Patients referred for the first time to a surgical service with a presumed diagnosis of hernia and eventual hernia repair were eligible, and those who gave consent completed a simple self-assessment questionnaire before the clinical visit.

RESULTS

The study population included 449 patients (72.8% men, mean age 61.5). Twenty (4.5%) patients did not have hernia on physical examination. The patient's perceived health status was "neither bad nor good" or "good" in 56.6% of cases. Also, more patients considered that hernia repair would be an easy procedure (35.1%) rather than a difficult one (9.8%). Although patients were referred by their family physicians, 32 (7.1%) answered negatively to the question of coming to the visit to assess the presence of a hernia. The most important reason of the medical visit was to receive medical advice (77.7%), to be operated on as soon as possible (40.1%) or to be included in the surgical waiting list (35.9%). Also, 46.1% of the patients considered that they should undergo a hernia repair and 56.8% that surgery will be a definitive solution.

CONCLUSION

PRK of patients referred for the first time to an abdominal wall surgery unit with a presumed diagnosis of hernia was quite limited and there is still a long way towards improving knowledge of hernia surgery.

Enhancing Family-Centered Care in Cardiothoracic Surgery

The psychological impact of critical illness is far reaching, affecting patients and their loved ones. Family members face a multitude of stressors, ranging from concerns about death or permanent disability to stress over health care costs and lost wages. Patients are at risk for developing post-intensive care syndrome. Professional groups and patient safety organizations have crafted family-centered care (FCC) models that support hospitalized patients and their families. There is a paucity of data on use of FCC in cardiothoracic intensive care units. This article discusses FCC models and why they are beneficial to the needs of families of postoperative cardiothoracic surgery patients.

Preoperative Optimism Related to Low Anxiety in Patients 1 Month After Open Heart Surgery

Anxiety can contribute to poor prognosis in cardiac patients. Few studies have examined the role of optimism in anxiety after open heart surgery (OHS). This study investigated the influence of preoperative optimism on post-OHS anxiety, adjusting cardiac indices used by cardiac surgeons. Data were collected before and 1 month after OHS in 481 patients (58% men; age, 62.4 ± 11.94 years). Optimism was measured using the Life Orientation Test. Anxiety was measured using the Trait Anxiety Inventory. Medical and cardiac indices were retrieved from the Society of Thoracic Surgeon's national database. Multiple regression analyses showed that greater pre-OHS optimism was associated with lower levels of post-OHS anxiety (F[6, N = 306] = 50.18, p < 0.001, R = 0.502). No other factors showed similar protection. Pre-OHS anxiety, younger age, and minority status were associated with anxiety in the critical recovery month. The findings demonstrate the potential benefit of optimism against post-OHS anxiety, which may have clinical implications for improving disease management.

Development of the generic, multidimensional Treatment Expectation Questionnaire (TEX-Q) through systematic literature review, expert surveys and qualitative interviews

OBJECTIVE

Patients' expectations-as a central mechanism of placebo and nocebo effects-are an important predictor of health outcomes. However, the lack of a way to assess expectations across different settings restricts progress in understanding the role of expectations and to quantify their importance in medical and psychological treatments. The aim of this study was to develop a theory-based, generic, multidimensional measure assessing patient expectations of medical and psychological treatments.

DESIGN

The Treatment Expectation Questionnaire (TEX-Q) was developed based on the integrative model of expectations and a systematic literature review of treatment expectation scales. After creating a comprehensive item pool, the scale was further refined by use of expert ratings and patient interviews.

SETTING

Patients were recruited in primary care at two hospitals in Hamburg, Germany.

PARTICIPANTS

13 scientific experts participated in the expert survey. 11 patients waiting for psychological or surgical treatments participated in the qualitative interviews.

RESULTS

The 2×2×2 multidimensional structure of the TEX-Q assesses two expectation constructs (probabilistic vs value-based) across two outcome domains with two valences (direct benefits and adverse events, broader positive and negative impact), plus process and behavioural control expectations. We examined 583 items from 38 scales identified in the systematic review and developed 78 initial items. Content validity was then rated by experts according to item fit and comprehensibility. The best 53 items were further evaluated for comprehensibility, acceptability, phrasing preference and understanding by interviewing patients prior to treatment using the 'think aloud' technique. This resulted in a first 35-item version of the TEX-Q.

CONCLUSIONS

The TEX-Q is a generic, multidimensional measure to assess patient expectations of medical and psychological treatments and allows comparison of the impact of multidimensional expectations across different conditions. The final TEX-Q will be available after psychometric validation.

Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018

Purpose and Objectives

Emergency departments see a disproportionate share of low-income and uninsured patients. We developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data.

Intervention Approach

We leveraged an academic–community partnership to develop a social needs screening tool and referral process.

Evaluation Methods

In a 25-day feasibility trial incorporating rapid improvement cycles, emergency department staff screened 210 patients for social needs. Observational and interview notes were analyzed, and data were linked from patient screenings, the United Way of Salt Lake 2-1-1 consumer information system, and electronic health records.

Results

Domains uncovered during pilot testing included screening based on appearance or insurance; discomfort asking stigmatizing questions; and lack of clarity regarding the screening’s purpose. During the trial, 61% (n = 129) of patients reported 1 or more need, 52% (n = 67) of whom wanted follow-up. Of the 65 patients with complete data who wanted referrals, 49% (n = 32) were ultimately reached by 2-1-1, which provided an average of 4 community referrals (eg, pharmacy programs, utility assistance). Service usage 3 months before versus 3 months after emergency department index dates demonstrated that patients with social needs experienced a significant increase in emergency department use compared with those without needs (1.07 vs 1.36, P = .03), while patients with no needs experienced increases in primary care visits compared with those patients with unmet needs (0.24 vs 0.56, P = .03).

Implications for Public Health

We demonstrated the ability to systematically screen and refer for emergency department patients’ unmet social needs by using existing resources and to link screening results, service referral details, and health service data. However, our experiences demonstrate that widespread implementation efforts should thoughtfully address staff perceptions and patient communication challenges.

Risk for non-home discharge following surgery for ischemic mitral valve disease

OBJECTIVES

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).

METHODS

Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.

RESULTS

NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P < .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P < .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.

CONCLUSIONS

NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

Impact of Preoperative Functional Status on Quality of Life after Cardiac Surgery

BACKGROUND

 With increasing importance, health-related quality of life (HRQoL) has become a crucial outcome measure of cardiac surgery. The aim of this study was to assess the dynamics of HRQoL change within 12 months after surgery and to identify predictors of deterioration in physical and mental health.

METHODS

 The cohort of this prospective study included 164 consecutive patients who underwent elective surgery. HRQoL was assessed on the basis of the Short-Form 36 questionnaire at three different times: upon admission and at 3 and 12 months after surgery. The minimal clinically important difference (MCID) was used to determine whether the surgery resulted in deterioration of HRQoL.

RESULTS

 In general, physical and mental health status improved within the first year after cardiac surgery. However, after 12 months, 7.9 and 21.2% of patients had clinically significant poorer physical (PCS) and mental component summary (MCS) scores, based on the MCID approach. The results of multivariate analysis identified preoperative health status, age < 70 years, coronary artery bypass grafting, and a previous neurological event as predictors of deterioration in postoperative HRQoL. The greatest risks for deterioration were higher preoperative PCS and MCS scores.

CONCLUSION

 Although we were able to demonstrate a general improvement in the HRQoL following cardiac surgery, in one-fifth of patients, there was no recovery of mental health status even after 1 year. As this effect is mainly determined by preoperative functional status, HRQoL should be an integral part of medical consultation, especially in younger patients with a positive perception of quality of life.

Subjective expectations regarding ageing: a cross-sectional online population survey in Hungary

BACKGROUND

We aimed to investigate individuals' subjective expectations regarding health and happiness alongside their provisions on life circumstances for older ages.

METHODS

A cross-sectional online survey was performed involving a representative sample (N = 1000; mean age 50.9, SD = 15.4; female 54.5%) in Hungary. Subjective expectations on health status (EQ-5D-3L/-5L, GALI, WHO-5), happiness (0-10 VAS), employment status, care time, and forms of care for ages 60, 70, 80, and 90 were surveyed.

RESULTS

Current mean EQ-5D-5L was 0.869 (SD = 0.164) and happiness was 6.7 (SD = 2.4). Subjective life expectancy was 80.9 (SD = 11.1), and median expected retirement age was 65. Mean expected EQ-5D-5L for ages 60/70/80/90 was 0.761/0.684/0.554/0.402, and no activity limitations (GALI) were expected by 64%/40%/18%/14%, respectively. Expected happiness score was 6.8/6.7/6.2/5.7, and a decrease in mental well-being (WHO-5) was provisioned. A substantial increase in drug expenses and care time was anticipated, but only 52% thought to have extra income besides pension. The great majority expected to be helped by the family (77%/72%/53%/40%) if needed. Educational level, GALI, and longevity expectations were significant predictors of EQ-5D-5L expectations using a standard 5% significance level of decision. Current happiness was major determinant of expected future happiness.

CONCLUSIONS

Individuals expect a significant deterioration of health with age but only a moderate decrease in happiness. Overestimation of future activity limitations suggests a gap between statistical and subjective healthy life expectancy. The majority expects to rely on informal care in the elderly. Raise in retirement age is underestimated. Our results can be used as inputs for economic modelling of labor force participation and ageing.

Impact of pre-operative health-related quality of life on outcomes after heart surgery

BACKGROUND

Long-term improvement in health-related quality of life (HRQOL) is one of the most important outcomes of cardiac surgery. The aim of this study is to define the impact of perioperative patient and procedural variables on HRQOL dynamics, a year after cardiac surgery.

METHODS

Consecutive patients undergoing elective on-pump cardiac surgery were enrolled in this prospective observational cohort study. Patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire a day before surgery and once again a year after surgery. The effect size method was used to determine whether treatment resulted in the improvement of HRQOL.

RESULTS

A total of 67.3% of patients achieved long-term improvement in HRQOL. Significant negative association was identified between Physical and Mental Component Summary scores (PCS/MCS) and long-term outcomes. Pre-operative PCS were 40.7 ± 13.7 for improvers and 56.6 ± 14.4 for non-improvers; MCS were 45.8 ± 12.1 and 65.2 ± 13.7, respectively (P < 0.001 for all). There were no statistically significant differences in pre-operative risk factors, demographics, operative factors or post-operative variables between the two groups.

CONCLUSION

Among those completing this study, one in three patients did not experience long-term HRQOL improvements following cardiac surgery. Multivariate analysis confirmed that higher pre-operative PCS and MCS are independent predictors of worse HRQOL a year after surgery. Further research should focus on establishing the prevalence of this phenomenon worldwide and develop targeted interventions to improve long-term self-perceived quality of life for patients with relatively good pre-operative health.

Patients' Expectations Regarding Medical Treatment: A Critical Review of Concepts and Their Assessment

Patients’ expectations in the context of medical treatment represent a growing area of research, with accumulating evidence suggesting their influence on health outcomes across a variety of medical conditions. However, the aggregation of evidence is complicated due to an inconsistent and disintegrated application of expectation constructs and the heterogeneity of assessment strategies. Therefore, based on current expectation concepts, this critical review provides an integrated model of patients’ expectations in medical treatment. Moreover, we review existing assessment tools in the context of the integrative model of expectations and provide recommendations for improving future assessment. The integrative model includes expectations regarding treatment and patients’ treatment-related behavior. Treatment and behavior outcome expectations can relate to aspects regarding benefits and side effects and can refer to internal (e.g., symptoms) and external outcomes (e.g., reactions of others). Furthermore, timeline, structural and process expectations are important aspects with respect to medical treatment. Additionally, generalized expectations such as generalized self-efficacy or optimism have to be considered. Several instruments assessing different aspects of expectations in medical treatment can be found in the literature. However, many were developed without conceptual standardization and psychometric evaluation. Moreover, they merely assess single aspects of expectations, thus impeding the integration of evidence regarding the differential aspects of expectations. As many instruments assess treatment-specific expectations, they are not comparable between different conditions. To generate a more comprehensive understanding of expectation effects in medical treatments, we recommend that future research should apply standardized, psychometrically evaluated measures, assessing multidimensional aspects of patients’ expectations that are applicable across various medical treatments. In the future, more research is needed on the interrelation of different expectation concepts as well as on factors influencing patients’ expectations of illness and treatment. Considering the importance of patients’ expectations for health outcomes across many medical conditions, an integrated understanding and assessment of such expectations might facilitate interventions aiming to optimize patients’ expectations in order to improve health outcomes.