Optimizing preoperative expectations in cardiac surgery patients is moderated by level of disability: the successful development of a brief psychological intervention

Preoperative optimization of cardiac valve patients' expectations: Study protocol of the randomized controlled ValvEx-trial

Introduction

Complete recovery after surgery depends on psychological factors such as preoperative information, expectations, and surgery-associated anxiety. Prior studies have shown that even a short preoperative psychological intervention aiming at optimized expectations (EXPECT) can improve postoperative outcomes in coronary artery bypass patients. However, this intervention may benefit only a small subgroup of heart surgery patients since implementing preoperative psychological interventions into the daily clinical routine is difficult due to the additional time and appointments. It is unclear whether the EXPECT intervention can be shortened and whether heart valve patients would also benefit from interventions that optimize patients' expectations. The multicenter ValvEx trial aims (i) to adapt an effective preoperative psychological intervention (EXPECT) to make it brief enough to be easily integrated into the preoperative routine of heart valve patients and (ii) to examine if the adapted preoperative psychological intervention improves the subjectively perceived illness-related disability (PDI) up to 3 months after surgery.

Materials and analysis

In two German university hospitals, N = 88 heart valve patients who undergo heart surgery are randomized into two groups [standard of care (SOC) vs. standard of care plus interventional expectation manipulation (SOC and EXPECT)] after baseline assessment. Patients in the EXPECT group additionally to standard of care participate in the preoperative psychological intervention (30-40 min), focusing on optimizing expectations and have two booster-telephone calls (4 and 8 weeks after the surgery, approx. 15 min). Both groups have assessments again on the evening before the surgery, 4 to 6 days, and 3 months after the surgery.

Discussion

The trial demonstrates excellent feasibility in the clinical routine and a high interest by the patients.

Ethics and dissemination

The Ethics Committees of the Department of Medicine of the Philipps University of Marburg and the Department of Medicine of the University of Giessen approved the study protocol. Study results will be published in peer-reviewed journals and presented at congresses.

Clinical trial registration

ClinicalTrials.gov, identifier NCT04502121.

Baseline depressive symptoms, personal control, and concern moderate the effects of preoperative psychological interventions: the randomized controlled PSY-HEART trial

This study examined whether baseline (3–14 days pre-surgery) levels of (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs moderate the effects of additional preoperative interventions before coronary artery bypass graft surgery on (i) depressive or (ii) anxiety symptoms and (iii) illness beliefs 1 day before surgery, 1 week and 6 months after surgery. In the PSY-HEART trial, 115 patients were assessed. They were randomized into one of three groups: 1. receiving standard medical care only (SMC), additional psychological interventions: 2. aiming to optimize patients’ expectations (EXPECT), or 3. focusing on emotional support. Patients with a higher baseline level of depressive symptoms receiving a preoperative psychological intervention indicated lower depressive symptoms 6 months after surgery compared to SMC. EXPECT increased personal control and concern levels in patients with low baseline personal control/concern 1 day before surgery. Brief preoperative psychological interventions can improve psychological outcomes in heart surgery patients. Baseline status may moderate these effects. The study has been approved by the medical ethics committee of the Philipps University of Marburg and has been pre-registered at www.clinicaltrials.gov (NCT01407055) on August 1, 2011.

IL-8 and CRP moderate the effects of preoperative psychological interventions on postoperative long-term outcomes 6 months after CABG surgery - The randomized controlled PSY-HEART trial

INTRODUCTION

Inflammation has been related to several somatic and psychological disorders and may moderate effects of psychological interventions. In the PSY-HEART trial patients benefitted from preoperative psychological interventions before undergoing coronary artery bypass graft surgery (CABG) and, if necessary, concomitant valvular surgery, compared to standard medical care. In this study we examined whether patients' baseline inflammatory status moderated the intervention effects.

MATERIAL AND METHODS

In a prospective three-arm randomized clinical trial with 6-months follow-up, 124 patients scheduled for CABG surgery alone or concomitant with valvular surgery were randomized to (i) standard medical care only (SMC) or two preoperative psychological interventions: (ii) CBT-based optimizing expectations (EXPECT) and an (iii) an active control group focusing on emotional support (SUPPORT). Available baseline CRP- (n = 79), IL-6- (n = 78), IL-8- (n = 78) and TNF-alpha-(n = 80) parameters were considered as potential moderators (CRP as a categorical and continuous moderator). Linear mixed model analyses were calculated to test whether baseline inflammatory levels moderated intervention effects on disability, mental and physical quality of life at 6 months after surgery.

RESULTS

IL-8 moderated intervention effects on patients' disability and categorical CRP moderated intervention effects on mental quality of life. Follow-up tests indicated that EXPECT (and in part SUPPORT) led to lower postoperative disability and higher mental quality of life compared to SMC in patients with low baseline inflammatory markers. EXPECT indicated higher mental quality of life compared to SUPPORT in the high CRP subgroup. Patients in the SMC group had higher mental quality of life in the high CRP subgroup compared to the low CRP subgroup.

CONCLUSION

Especially for patients with a lower inflammatory baseline status preoperative psychological interventions might be helpful to optimize long-term CABG surgery outcomes.

The effects of patients' expectations on surgery outcome in total hip and knee arthroplasty: a prognostic factor meta-analysis

Patients' expectations are among the most frequently studied psychological prognostic factors in total knee and hip arthroplasty (TKA/THA). So far, however, evidence on the effect of patients' preoperative expectations on surgery outcome is inconclusive. Heterogeneity of expectation constructs and the use of psychometrically not evaluated measurement instruments have constituted major obstacles for the integration of the current literature. Using a theory-based model of expectation constructs , this meta-analysis set out to disentangle the conflicting results in the current literature. Systematic literature searches yielded k = 46 studies (N = 10,465) that reported associations of preoperative expectations with postoperative pain, functioning and disability, and satisfaction. Random effects meta-analysis revealed a robust small association (r = .16; 95% CI .13, .19) between patients' positive preoperative expectations and better postoperative outcomes. This effect did not differ between THA and TKA, different outcome categories and different follow-up periods. Studies using psychometrically evaluated expectation measures reported significantly higher effects (r = .19; 95% CI .16, .22). Whether this effect varies among different expectation constructs remains unclear. High-quality studies using validated, multidimensional expectation measures are needed to further understand the role of different expectation constructs in THA and TKA surgery.

Optimizing patient expectations to improve therapeutic response to medical treatment: A randomized controlled trial of iron infusion therapy

OBJECTIVES

Patient expectations have the ability to influence health outcomes and have been shown to play an important role as part of the placebo effect to influence the response to medical treatments. Increasing positive expectations have been proposed as an intervention to improve treatment response, although evidence for this to date is limited. We investigated whether a brief 10-min intervention directly targeting patient expectations prior to an iron infusion could enhance expectations and improve treatment response, in terms of patients' reported fatigue.

DESIGN

Randomized controlled trial.

METHODS

Forty-three patients diagnosed with iron deficiency anaemia were randomized to a brief expectation intervention or active control group prior to an intravenous iron infusion. Chalder Fatigue Scale scores were assessed prior to randomization and at one and four weeks.

RESULTS

The expectation intervention significantly improved patients' expectations about the effectiveness of the intravenous iron infusion, t(21) = -3.95, p = .001. While there were no significant differences between groups in fatigue at the one-week follow-up, fatigue was significantly lower in the intervention group at the four-week follow-up compared to the control group, F(1, 25) = 6.25, p = .019. This was largely influenced by a significant reduction in physical, as opposed to mental fatigue scores.

CONCLUSIONS

Boosting patients' positive expectations may be an effective way of enhancing patient response to treatment. In particular, targeting patient expectations with a brief intervention prior to medical treatments may result in a greater and longer therapeutic effect.

Optimizing expectations about endocrine treatment for breast cancer: Results of the randomized controlled psy-breast trial

Background

Medication side effects are strongly determined by non-pharmacological, nocebo mechanisms, particularly patients’ expectations. Optimizing expectations could minimize side effect burden. This study evaluated whether brief psychological expectation management training (EXPECT) optimizes medication-related expectations in women starting adjuvant endocrine therapy (AET) for breast cancer.

Method

In a multisite randomized controlled design, 197 women were randomized to EXPECT, supportive therapy (SUPPORT), or treatment as usual (TAU). The three-session cognitive-behavioral EXPECT employs psychoeducation, guided imagery, and side effect management training. Outcomes were necessity-concern beliefs about AET, expected side effects, expected coping ability, treatment control expectations, and adherence intention.

Results

Both interventions were well accepted and feasible. Patients’ necessity-concern beliefs were optimized in EXPECT compared to both TAU and SUPPORT, d = .41, p < .001; d = .40, p < .001. Expected coping ability and treatment control expectations were optimized compared to TAU, d = .35, p = .02; d = .42, p < 001, but not to SUPPORT. Adherence intention was optimized compared to SUPPORT, d = .29, p = .02, but not to TAU. Expected side effects did not change significantly.

Conclusion

Expectation management effectively and partly specifically (compared to SUPPORT) modified medication-related expectations in women starting AET. Given the influence of expectations on long-term treatment outcome, psychological interventions like EXPECT might provide potential pathways to reduce side effect burden and improve quality of life during medication intake.

Positive experience with treatment is associated with better surgical outcome in trapeziometacarpal osteoarthritis

The aim of this study was to investigate the association between patients' experiences with trapeziometacarpal arthroplasty and treatment outcomes in terms of patient-reported outcome measures, grip and pinch strength. We included 233 patients who received a Weilby procedure for trapeziometacarpal osteoarthritis. Before surgery and 12 months after surgery, patients completed the Michigan Hand Outcomes Questionnaire, and their pinch and grip strengths were measured. At 3 months after surgery, a patient-reported experience measure was completed. Using regression analysis, significantly positive associations were found between the Michigan Hand questionnaire and the patient-reported experience measure, with the strongest significant associations being for patients' experiences with information provision. No significant associations were found between the patients' experience and strength outcomes. The results highlight the potential importance of positive experience with the treatment process to improve treatment outcomes in patients undergoing surgery for trapeziometacarpal osteoarthritis. Level of evidence: IV.

Illness Perception and Its Changes During Six Months After Cardiac Rehabilitation

Abstract. Illness perception is a concept that reflects patients' emotional and cognitive representations of disease. This study assessed the illness perception change during 6 months in 195 patients (33% women and 67% men) with acute coronary syndrome, taking into account the biological, psychological, and social factors. At baseline, more threatening illness perception was observed in women, persons aged 65 years or more, with poorer functional capacity (New York Heart Association [NYHA] class III or IV) and comorbidities ( p < .05). Type D personality was the only independent factor related to more threatening illness perception (βs = 0.207, p = .006). At follow-up it was found that only self-reported cardiovascular impairment plays the role in illness perception change (βs = 0.544, p < .001): patients without impairment reported decreasing threats of illness, while the ones with it had a similar perception of threat like at baseline. Other biological, psychological, and social factors were partly associated with illness perception after an acute cardiac event but not with perception change after 6 months.

Better patients' treatment experiences are associated with better postoperative results in Dupuytren's disease

This prospective study investigates the extent to which a better experience with healthcare delivery is associated with better postoperative treatment outcomes after surgery for Dupuytren's contracture. Patients undergoing limited fasciectomy or percutaneous needle fasciotomy for Dupuytren's contractures completed the Michigan Hand Outcomes Questionnaire before and 3 months after surgery, together with a patient reported experience measure, while hand therapists assessed the straightness of the finger with a goniometer. Regression analyses were used to examine associations. We found that a better experience with healthcare delivery was associated with better patient-reported outcomes, while association with residual extension deficit was minimal. Strongest associations were seen with communication of the physician, postoperative care and information about the treatment. Experience with the treatment explained up to 12% of the variance in treatment outcome. These findings suggest that patient reported treatment outcomes in Dupuytren's disease can be improved by improving the treatment context.

LEVEL OF EVIDENCE

II.

Optimizing preoperative expectations leads to a shorter length of hospital stay in CABG patients: Further results of the randomized controlled PSY-HEART trial

OBJECTIVE

To examine the effect of a preoperative expectation-optimizing psychological intervention on length of stay in the hospital and time spent in the Intensive Care Unit (ICU) in patients undergoing elective cardiac surgery.

METHODS

In a randomized controlled trial, 124 patients prior to undergoing coronary artery bypass grafting (CABG) or CABG combined with heart valve surgery were randomized to either a) standard medical care alone (SMC) or an additional preoperative intervention, b) an additional expectation manipulation intervention (EXPECT) to optimize patients' expectations, or c) an additional supportive therapy (SUPPORT), containing the same amount of therapeutic attention but without a specific focus. Participants were followed-up post-operatively to assess their length of hospital stay and the time spent in the ICU.

RESULTS

Patients in both psychological intervention groups spent significantly less days in the hospital then patients in the SMC group (M(EXPECT)=12.62, M(SUPPORT)=14.13, M(SMC)=17.27, p=0.028). There was a significant linear trend (F(1112)=7.68, p=0.009) showing that the more specific the intervention patients received the shorter they stayed in the hospital. The effect of the intervention on time spent in the ICU was only marginally significant (M(EXPECT)=103.76, M(SUPPORT)=103.10, M(SMC)=158.45, p=0.066).

CONCLUSION

Changing patients' preoperative expectations via a psychological intervention leads to less days spent in the hospital. The psychological interventions are associated with positive cost-benefit ratios. Specific psychological mechanisms underlying the effect of our intervention remain unclear and need to be investigated further.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT01407055).

Physicians' beliefs about placebo and nocebo effects in antidepressants - an online survey among German practitioners

BACKGROUND

While substantial placebo and nocebo effects have been documented in antidepressant clinical trials, physicians' awareness of the nonspecific effects in routine antidepressant treatment remains unclear. The study investigated physicians' beliefs and explanatory models regarding the desired effects and undesired side effects of antidepressants, with specific emphasis on nonspecific effects accounted for by placebo and nocebo mechanisms.

METHODS

An online survey was conducted among 87 physicians (40.2% psychiatrists, 25.3% neurologists, 24.1% general practitioners, 12.6% internists, 21.8% other). The survey assessed the physician's beliefs in antidepressant effectiveness, as well as 6 explanatory models regarding antidepressant effectiveness and 8 explanatory models for the occurrence of side effects.

RESULTS

Most physicians (89.7%) believed in the effectiveness of antidepressants while acknowledging a considerable role of the placebo effect by attributing around 40% of the total effects to nonspecific factors. For both antidepressant effectiveness and the occurrence of side effects, pharmacological effects were rated as most important (93.1% and 80.5% agreement), but physicians also attributed a substantial role to the patients' expectations (63.2% and 58.6%) and experiences (60.9% and 56.3%). Concerning the physician's own role in promoting nonspecific effects in antidepressant effectiveness, highest endorsements were found for the quality of the physician-patient-relationship (58.6%) and own expectations (41.4%). When asked about side effects, fewer participants agreed that informing the patient about known side effects (25.2%) or the physicians' expectations themselves (17.2%) could induce side effects.

CONCLUSION

Physicians, when prescribing antidepressants, are generally open towards nonspecific treatment mechanisms. However, they consider their own influence as less important than the patient's side, especially when it comes to the explanation of unwanted side effects. Awareness of the possible beneficial as well as malicious role of nonspecific mechanisms should be fostered as the first step towards optimizing antidepressant treatment by promoting placebo while avoiding nocebo effects.

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.

Preoperative optimization of patient expectations improves long-term outcome in heart surgery patients: results of the randomized controlled PSY-HEART trial

BACKGROUND

Placebo effects contribute substantially to outcome in most fields of medicine. While clinical trials typically try to control or minimize these effects, the potential of placebo mechanisms to improve outcome is rarely used. Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects. We aimed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

In a prospective three-arm randomized clinical trial with a 6 month follow-up, 124 patients scheduled for CABG surgery were randomized to either a brief psychological pre-surgery intervention to optimize outcome expectations (EXPECT); or a psychological control intervention focusing on emotional support and general advice, but not on expectations (SUPPORT); or to standard medical care (SMC). Interventions were kept brief to be feasible with a heart surgery environment; "dose" of therapy was identical for both pre-surgery interventions. Primary outcome was disability 6 months after surgery. Secondary outcomes comprised further clinical and immunological variables.

RESULTS

Patients in the EXPECT group showed significantly larger improvements in disability (-12.6; -17.6 to -7.5) than the SMC group (-1.9; -6.6 to +2.7); patients in the SUPPORT group (-6.7; -11.8 to 1.7) did not differ from the SMC group. Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group (P = 0.09). Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work (hours per week). Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up. Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them. Considering the innovative nature of this approach, replication in larger, multicenter trials is needed.

CONCLUSIONS

Optimizing patients' expectations pre-surgery helps to improve outcome 6 months after treatment. This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions. Further studies are warranted to generalize this approach to other fields of medicine.

TRIAL REGISTRATION

Ethical approval for the study was obtained from the IRB of the Medical School, University of Marburg, and the trial was registered at ( NCT01407055 ) on July 25, 2011.

Welche Erwartungen sagen postoperative Depressivität und Ängstlichkeit bei herzchirurgischen Patienten am stärksten vorher?

Zusammenfassung. Theoretischer Hintergrund: Depressivität und Ängstlichkeit beeinträchtigen den Behandlungserfolg von herzchirurgischen Patienten. Fragestellung: Untersucht wurde, ob und wie präoperative Patientenerwartungen mit postoperativer Depressivität und Ängstlichkeit zusammenhängen und welche präoperativen Erwartungen hierbei den höchsten prädiktiven Wert haben. Methoden: 124 aortocoronare Bypass-Patienten bearbeiteten eine Woche vor der Operation einen Fragebogen, der verschiedene Aspekte von Erwartungen mischt (Positive Health Expectation Questionnaire; PHES) und einen Fragebogen, der einzelne Erwartungsaspekte getrennt erfasst (Expected Illness Perception Questionnaire, IPQ-E) und eine Woche vor sowie eine Woche nach der Operation Fragen zu ihrer Depressivität und Ängstlichkeit (Hospital Anxiety and Depression Scale (HADS)). Ergebnisse: Postoperative Depressivität wird durch präoperative Erwartungen vorhergesagt (R2 = 0.32, F = 3.13, p = .02). Der einzig signifikante Prädiktor hierbei sind positive Gesundheitserwartungen gemessen mit dem PHES. Auch postoperative Ängstlichkeit wird durch präoperative Erwartungen vorhergesagt (R2 = 0.27, F = 2.55, p < .05). Bei der Vorhersage postoperativer Ängstlichkeit haben erwartete Konsequenzen gemessen mit dem IPQ-E den stärksten prädiktiven Wert. Schlussfolgerungen: Die Studie belegt die Relevanz von präoperativen Erwartungen bei herzchirurgischen Patienten. Interventionen, die auf die Verringerung von Depressivität herzchirurgischer Patienten abzielen, sollten den Fokus auf verschiedene Aspekte von Erwartungen legen. Bei der Verringerung postoperativer Ängstlichkeit könnten hingegen einzeln erfasste Erwartungsaspekte von Bedeutung sein.

Overlap and Differences Between Patient and Provider Expectations for Treatment Outcomes: The Case of Acupuncture

Our study aimed to identify patient-provider clusters with different patterns of expectations for treatment outcomes. All patients (n = 885) received acupuncture treatment from physicians for their migraine, headache, osteoarthritis, or chronic low back pain. We identified 6 robust patient-provider expectation clusters (PPECs; interclassification reliability >.89) showing differences between patients and providers in their expected treatment responses (eg, unrealistic optimists, optimistic doubters). For example, the optimistic doubters had high expectations for their treatment outcomes but were skeptical of the benefits of acupuncture in general. The providers expected good improvements for these patients. These 6 PPECs differed in their clinical characteristics and in the associated treatment responses. For example, unrealistic optimists showed the weakest treatment benefits after 6 months; other PPECs and clinical patterns are also presented in the report. Our study suggests that comparing the expectations of patients and providers is a valuable approach to identify groups of patients with greater responsiveness and those with limited treatment benefits.

PERSPECTIVE

Patients and providers of acupuncture might vary in their expectation of the treatment effect and in clinical practice the overlap of expectations of patients and providers should be considered as important in initial consultations.

Health-related personal control predicts depression symptoms and quality of life but not health behaviour following coronary artery bypass graft surgery

To determine the prospective association between health-related control beliefs, quality of life (QOL), depression symptoms, and health behaviours in coronary artery bypass graft (CABG) patients 6-8 weeks following surgery. 149 patients who were undergoing planned CABG surgery were recruited. Patients completed questionnaires measuring health related personal control, treatment control, depression symptoms, QOL, and health behaviours prior to and 6-8 weeks after surgery. Higher levels of health-related personal control predicted better QOL, and lower levels of depression symptoms, but not adherence to medication, cardiac rehabilitation attendance, or physical activity. These results were independent of demographic, behavioural, and clinical covariates. Treatment control was not associated with any outcome. These results suggest that perceived health-related personal control is associated with key aspects of short-term recovery from CABG surgery. Targeted interventions aimed at improving perceptions of health-related personal control may improve health outcomes in this cardiac population.