Patients' expectations of cervical spine surgery

Patient Expectations and Satisfaction in Pediatric Orthopedics

PURPOSE OF REVIEW

The purpose of the current review is to analyze the current literature regarding the tools available to evaluate patient expectations and satisfaction. There have been an increasing number of tools that have been developed and validated for various orthopedic procedures. Despite the growing number of tools, there are a limited number of tools available for pediatric patients.

RECENT FINDINGS

Several tools have been developed in orthopedics to evaluate patient expectations. However, there are no tools that have been validated in the pediatric population. In addition, pediatric patient expectations should be collected in conjunction with parent/caregiver expectations. Although not specifically validated for pediatric patients, there are several tools available that may pertain to pediatric patients including the HSS ACL Expectations Survey, HSS Shoulder Expectations Survey, HSS Knee Surgery Expectations Survey, HSS Foot and Ankle Surgery Expectation Survey, Sunnybrook Surgery Expectations Survey, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) Instruments, Quick DASH, and DASH. In terms of patient satisfaction, there are even fewer tools available. Several tools have been developed to evaluate patient satisfaction and five additional tools within orthopedics. Of these tools, there are two that have been validated for pediatric patients: The Swedish Parents Satisfaction Questionnaire and the Scoliosis Research Society-22. There are a growing number of tools to evaluate patient's expectations and satisfaction in the orthopedic literature. Given most of these tools pertain to adult patients, there is a need for further development of tools specifically validated for pediatric patients and their parents/caregivers. Through the measurement of expectations and satisfaction, medical professionals can hope to improve satisfaction and outcomes.

Preoperative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

BACKGROUND

Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about preoperative expectations of these patients.

PURPOSE

The primary objective was to describe patient preoperative expectations. Secondary objectives included identifying patient characteristics associated with high preoperative expectations and to determine if expectations varied depending on myelopathy severity.

STUDY DESIGN

This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM.

PATIENT SAMPLE

Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included.

OUTCOMES MEASURES

An 11-domain expectation questionnaire was completed preoperatively whereby patients quantified the expected change in each domain.

METHODS

The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models.

RESULTS

There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p=.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05-0.37, p=.01).

CONCLUSIONS

Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury

PURPOSE

Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery.

METHODS

We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race.

RESULTS

Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race.

CONCLUSIONS

Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Factors Influencing Surgical Decision Making in Trapeziometacarpal Osteoarthritis

Purpose

With trapeziometacarpal osteoarthritis (TMC OA), the relationship between disease severity and pretreatment dysfunction, patient expectations, and preferred patient treatment and management remains unclear. This study aimed to assess the association between functional status, pretreatment expectations, and demographic and clinical characteristics of TMC OA patients who decide to undergo operative management.

Methods

Patients diagnosed with TMC OA (n = 96) were administered the Thumb Arthritis Expectations Survey and the Brief Michigan Hand Questionnaire (bMHQ) during their initial office visit. Demographic data (sex, age, race, education level, marital status, comorbidities, and hand dominance) and clinical characteristics (prior injury, and therapeutic interventions including splinting, steroid injections, therapy, and anti-inflammatory medication) were collected. Multiple logistic regression was used to assess the association between surgical treatment and expectation scores.

Results

Our logistic regression model found that lower bMHQ scores, high thumb arthritis expectation survey scores, and prior treatments for TMC OA were associated significantly with the surgical treatment of TMC OA. After controlling for all possible covariates, the odds of having surgery was 3.9 times higher among patients with high expectations (above median) compared to patients with low expectations (adjusted odds ratio [AOR], 3.9; 95% confidence interval [CI], 1.3-11.2). Patients with average function, as measured by bMHQ scores, were 74.5% less likely to elect for surgery than those with the lowest bMHQ (AOR, 0.3; 95% CI, 0.1-0.9). Patients treated previously with steroids were 13 times more likely to elect for surgery than those who were never treated for TMC arthritis (AOR,13.1; 95% CI, 2.2-77.0).

Conclusions

Patients with TMC OA who elect to proceed with surgical management have lower bMHQ (greater perceived dysfunction) and higher expectations, and have had prior treatment. Age was not a significant predictor of surgical management of TMC OA.

Type of study/level of evidence

Prognostic IV.

Development and Validation of a Survey to Measure Patients' Expectations of Wrist Arthritis Surgery

Background  The purpose of this study was to develop and test a patient-derived expectations survey for wrist arthritis surgery. We hypothesized that preoperative patient expectations are higher in people with greater functional impairment and that postoperative fulfilment of patient expectations correlates with functional improvement. Methods  The study was conducted in four phases. Development (n = 22) Preoperatively, patients were asked open-ended questions regarding expectations of surgery. A draft survey was then assembled. Reliability (n = 35) The survey was administered twice preoperatively. Concordance was measured with weighted kappa values and intraclass correlations (ICC). Validity (n = 58) Validity was assessed by comparing responses from the Expectations Survey to the patient-rated wrist evaluation (PRWE). Responsiveness (n = 18) Responsiveness was calculated by comparing the proportion of expectations fulfilled to PRWE scores 1-year postoperatively. Results   Development Twenty-two distinct items representing the most frequent responses were utilized from the draft survey items of 1,244 expectations volunteered. Reliability Patients had high preoperative expectations of surgery (mean = 76.8); 30% had scores ≥90. Test-retest reliability was high (Cronbach α coefficients = 0.91, 0.93, ICC = 0.86). Endorsement of items = 66 to 100%; and weighted kappa values = 0.39 to 0.96. Validity Patients with greater preoperative expectations (≥63) had more pain, worse function, and worse PRWE scores than those with lower expectations. Responsiveness The proportion of fulfilled expectations was high (mean 0.80, median 0.79), and greater fulfillment (proportion > 0.80, n  = 8) was associated with better postoperative PRWE scores. Conclusion  The patient-derived expectations survey is reliable, valid, responsive, and addresses a spectrum of expectations for patients undergoing surgery for wrist arthritis. Clinical relevance Understanding patient expectations can contribute to customized care given the range of surgical choices for the arthritic wrist.

Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXT

Preoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis.

PURPOSE

The primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment.

STUDY DESIGN/SETTING

Patients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry.

PATIENT SAMPLE

Patients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included.

OUTCOME MEASURES

The North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year.

METHODS

Expectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression.

RESULTS

Three hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures. Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001]. Postoperative expectations fulfillment did not differ between procedures.

CONCLUSION

Preoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures.

Patient expectations and satisfaction in hand surgery: A new assessment approach through a valid and reliable survey questionnaire

INTRODUCTION

Assessing patient expectations in orthopaedic surgery has gained significant importance over time. However, there have been only a few studies on how to measure such expectations in hand surgery. Against the backdrop, the study was designed to develop a valid and reliable expectations survey for patients undergoing hand surgery and to identify the correlations between preoperative expectations and postoperative satisfaction.

MATERIALS AND METHODS

This is a three-phase prospective cohort study. In the first phase of the study (146 patients), patient expectations were assessed while developing a draft questionnaire based on frequency and clinical relevance. In the second phase (154 patients newly included), test-retest reliability was measured to ensure test consistency. The Intraclass Correlation Coefficient (ICC) served as a basis for developing the final survey questionnaire. In the third phase, we followed up with patients, who completed the preoperative expectations survey, 3 months after surgery to assess the fulfillment of their expectations. The Pearson correlation method was used to measure the association between preoperative expectations and postoperative satisfaction.

RESULTS

In the first phase, 146 patients shared 406 different expectations, which were grouped into nine categories. Then, in the second phase, the final survey was populated by questionnaire items under respective category that have revealed strong test-retest reliability (ICC of 0.91). A significant positive correlation between patient expectations and satisfaction was observed (R = 0.181, p = 0.034).

CONCLUSION

The survey was designed to offer a valid and reliable approach for the comprehensive assessment of patient expectations in hand surgery. The survey results show that patients with high expectations tend to be more satisfied with surgical outcomes. It is strongly believed that this approach would serve as a useful tool at a time when patient perspective is taken into account increasingly more in the clinical practice.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction Among Lumbar Fusion Patients

Study Design

Retrospective cohort.

Purpose

To investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.

Overview of Literature

Few studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.

Methods

A surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.

Results

A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.

Conclusions

The majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.

Association of Depression and Anxiety With Expectations and Satisfaction in Foot and Ankle Surgery

INTRODUCTION

Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients.

METHODS

Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients.

RESULTS

Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011).

DISCUSSION

Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management.

LEVEL OF EVIDENCE

Level III; retrospective review of prospective cohort study.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study

OBJECTIVE

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients.

METHODS

Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected.

RESULTS

There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not.

CONCLUSIONS

Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies

Background

Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care.

Methods

A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality.

Results

The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates.

Conclusions

Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes.

Trial registration

PROSPERO registration number: CRD42020145151.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07683-7.

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy

STUDY DESIGN

Retrospective analysis of prospectively collected registry data.

OBJECTIVE

To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

METHODS

This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

RESULTS

Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

CONCLUSIONS

These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

LEVEL OF EVIDENCE

2.

Patients' expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND

Understanding patient expectations is a critical component of patient-centered care; however, little is known about which expectation(s) are most important to patients as they relate to their sense of postoperative success.

PURPOSE

To investigate patient's preoperative expectations of change in symptoms, function, and well-being resulting from surgical intervention and to examine the associations between sociodemographic, lifestyle, health status, and clinical characteristics with patient outcome expectations STUDY DESIGN: Observational cross-sectional study.

SAMPLE

Preoperative data from the Canadian Spine Outcomes and Research Network national registry of patients of patients (n=4,333) undergoing surgery for degenerative spinal conditions between 2012 and 2017.

OUTCOME MEASURES

Patients reported their expectations as a result of the surgery (0 [no change], 1 [somewhat better], 2 [better] or 3 [much better]) for seven items: leg/arm pain, back/neck pain, independence in everyday activities, sporting activities/recreation, general physical capacity, frequency and quality of social contacts, and mental well-being. Patients also reported the single most important change expected.

METHODS

Data on demographic, lifestyles, health status, clinical factors, and reasons for having surgery were also collected. Factor analysis was used to examine the multidimensionality of expectations. Multivariate linear regression was used to examine factors associated with expectations.

RESULTS

Over 80% of patients reported expectation for improvements (at least somewhat better) in all items with the exception of social contacts (75.8%). Expectations are multidimensional; a two factor structure emerged indicating two expectation dimensions (pain relief and overall functional well-being). Two expectation scores were calculated corresponding to the two dimensions (0-100), with higher scores reflecting higher expectations. The mean±standard deviation pain relief expectation score was 78.5±24.7 and the mean overall functional well-being expectation score was 69.7±24.4. In multivariate analysis, the variables associated with these dimensions either differed or differed in degree of influence. For example, higher pain and disability scores, thoracolumbar location and diagnosis of spondylolisthesis were associated with higher expectations in both dimensions, while longer disease duration was only associated with lower overall functional well-being expectations. The top three most important expected change items were pain (improvement of leg or arm pain (29.1%)/improvement in back/neck pain (26.0%)), improvement in general capacity/function (21.0%), and improvement of independence in everyday activities (15.9%). Rankings of the most important expected change were similar across sociodemographic, lifestyle, health status, and clinical variables examined.

CONCLUSIONS

Our findings highlight the need to identify and address specific individual expectations as part of the shared decision-making and presurgery education process.

Pain neuroscience education: Which pain neuroscience education metaphor worked best?

BACKGROUND

The use of pain neuroscience education (PNE) has been shown to be effective in reducing pain, improving function and lowering fear and catastrophisation. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. To date no individualised study has looked at which stories and metaphors may be the most effective in achieving the positive outcomes found with the use of PNE.

OBJECTIVES

This study examined patient responses to the usefulness of the various stories and metaphors used during PNE for patients who underwent surgery for lumbar radiculopathy.

METHOD

Twenty-seven participants who received preoperative PNE from a previous randomised control trial (RCT) were surveyed 1-year post-education utilising a 5-point Likert scale (0 - 'do not remember', 4 - 'very helpful') on the usefulness of the various stories and metaphors used during the PNE session. Participant demographics and outcomes data (pain intensity, function and pain knowledge) were utilised from the previous RCT for analysis and correlations.

RESULTS

Nineteen surveys were returned for a response rate of 70%. No story or metaphor mean was below 2 - 'neutral', lowest mean at 2.53; 6 of the 11 stories or metaphors scored a mean above 3 - 'helpful'.

CONCLUSION

No individual story or metaphor stood out as being predominately important in being helpful in the recovery process through the use of PNE.

CLINICAL IMPLICATIONS

The overall messages of reconceptualising pain during PNE may be more important than any individual story or metaphor.

Preoperative patient expectations of elective reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine patients' preoperative expectations before primary elective reverse shoulder arthroplasty (RSA). We hypothesized that younger patients, patients with better preoperative function, patients with shoulder osteoarthritis (OA), and patients with no prior joint replacements would have higher expectations of RSA.

METHODS

We prospectively studied 333 primary RSAs performed for cuff tear arthropathy (n = 242), OA (n = 68), or post-traumatic arthritis (n = 23). Expectations were assessed preoperatively using the Hospital for Special Surgery's shoulder surgery expectations survey. Preoperative patient-reported measures were assessed with the American Shoulder and Elbow Surgeons shoulder score; Shoulder Activity Scale score; Short Form 12 mental component and physical component scores; and visual analog scale scores for pain, fatigue, and general health. A Poisson regression model was performed to control for potential confounding variables.

RESULTS

Relief of night-time pain, relief of daytime pain, improvement in self-care, improvement in the ability to drive or put on a seat belt, and improvement in the ability to perform daily activities were reported as "very important" by approximately half of patients. No association was found between age and overall expectations. Multivariate analysis showed that better preoperative Shoulder Activity Scale and Short Form 12 physical component scores were associated with greater expectations (P < .001). OA was associated with greater expectations compared with cuff tear arthropathy (P < .001). A history of either contralateral RSA or any joint replacement was associated with lower expectations (P < .001).

CONCLUSION

Patients have the highest expectations for pain relief and the performance of simple tasks after RSA. Patients with higher preoperative function, OA, and no previous joint replacements have greater expectations of RSA.

Patients' Expectations of Hip Preservation Surgery: A Survey Study

PURPOSE

To administer the Hip Preservation Surgery Expectations Survey to a large sample of patients to ascertain the prevalence of their preoperative expectations and to assess expectations in terms of demographic and clinical characteristics.

METHODS

Consecutive patients were enrolled if they were ≥18 years old/spoke English and excluded if they had prior hip surgery/degenerative changes Tönnis ≥2. Patients completed the 21-item survey addressing the amount of improvement expected for each item (number of items and an overall score were determined) and the International Hip Outcome Tool (iHOT; hip score determined). Analyses included multivariable regression with survey score and number of expectations as dependent variables. Subanalyses considered collegiate/professional, competitive, and recreational sports level.

RESULTS

Three hundred two patients participated, with a mean age of 32; 270 (89%) had cam impingement, 72 (24%) had symptoms <6 months, and mean iHOT score was 41. One hundred twenty patients (40%) selected all 21 survey items, 112 (37%) selected 18 to 20, and 70 (23%) selected ≤17 items. In multivariable analysis, younger age (odds ratio [OR] = 1.3; P = .02), symptoms <6 months (OR = 1.3; P = .03), and worse iHOT score (OR = 2.5; P = .0001) were associated with selecting more items. The mean survey score was 80 (range, 31-100). In multivariable analysis, younger age (P = .05), symptoms <6 months (P = .01), and worse iHOT score (P = .03) were associated with greater survey scores. Collegiate/professional athletes selected more items (P = .01) and were more likely to select improvement in sports performance (OR = 7.5; P = .001), achievement of athletic potential (OR = 3.7; P = .002), and maintaining options for more demanding future activities (OR = 2.7; P = .01).

CONCLUSIONS

Patients had multiple expectations for marked improvement in current and future physical function and psychological well-being. Younger patients, shorter symptom duration, and worse hip-specific functional status were associated with greater expectations. Understanding patients' expectations can guide preoperative education regarding realistic expectations for recovery and long-term outcome.

CLINICAL RELEVANCE

Patients' preoperative expectations vary according to demographic and clinical characteristics as measured in a survey study.

Predictive Model for Medical and Surgical Readmissions Following Elective Lumbar Spine Surgery: A National Study of 33,674 Patients

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here we aim to develop predictive models for 3-month medical and surgical readmission after elective lumbar surgery, based on a multi-institutional, national spine registry.

SUMMARY OF BACKGROUND DATA

Unplanned readmissions place considerable stress on payers, hospitals, and patients. Medicare data reveals a 30-day readmission rate of 7.8% for lumbar-decompressions and 13.0% for lumbar-fusions, and hospitals are now being penalized for excessive 30-day readmission rates by virtue of the Hospital Readmissions Reduction Program.

METHODS

The Quality and Outcomes Database (QOD) was queried for patients undergoing elective lumbar surgery for degenerative diseases. The QOD prospectively captures 3-month readmissions through electronic medical record (EMR) review and self-reported outcome questionnaires. Distinct multivariable logistic regression models were fitted for surgery-related and medical readmissions adjusting for patient and surgery-specific variables.

RESULTS

Of the total 33,674 patients included in this study 2079 (6.15%) reported at least one readmission during the 90-day postoperative period. The odds of medical readmission were significantly higher for older patients, males versus females, African Americans versus Caucasion, those with higher American Society of Anesthesiologists (ASA) grade, diabetes, coronary artery disease, higher numbers of involved levels, anterior only or anterior-posterior versus posterior approach; also, for patients who were unemployed compared with employed patients and those with high baseline Oswestry Disability Index (ODI). The odds of surgery-related readmission were significantly greater for patients with a higher body mass index (BMI), a higher ASA grade, female versus male, and African Americans versus Caucasians; also, for patients with severe depression, more involved spinal levels, anterior-only surgical approaches and higher baseline ODI scores.

CONCLUSION

In this study we present internally validated predictive models for medical and surgical readmission after elective lumbar spine surgery. These findings set the stage for targeted interventions with a potential to reduce unnecessary readmissions, and also suggest that medical and surgical readmissions be treated as distinct clinical events.

LEVEL OF EVIDENCE

3.

Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Patient expectations have been shown to be an independent predictor of outcomes in clinical medicine. In the orthopaedic literature, the majority of studies have focused on the relationship between pre-operative expectations and post-operative outcomes in patients undergoing total hip arthroplasty, total knee arthroplasty, shoulder surgery, and spine surgery. Various methodologies have been used to assess patient expectations in orthopaedic surgery, including direct questioning, short questionnaires, and validated surveys. Multiple patient factors have been associated with greater expectations prior to elective orthopaedic surgery, and greater pre-operative expectations have been shown to be associated with better subjective and objective outcomes after total hip and knee arthroplasty, shoulder surgery, and spine surgery. While there are very few validated measures of patient satisfaction after orthopaedic surgery, increased post-operative patient satisfaction is consistently associated with meeting pre-operative patient expectations. Given the relationship between pre-operative patient expectations and post-operative outcomes and patient satisfaction, understanding and defining expectations prior to elective orthopaedic surgery may optimize outcomes. In this review, we aim to summarize the current literature on patient expectations in orthopaedic surgery.

Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes.

METHODS

Patients undergoing primary RSA completed the Hospital for Special Surgery's Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors.

RESULTS

We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = -5.9, P = .047) as well as 2-year improvement of VAS pain (β = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020).

CONCLUSION

A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA.

Patient and Surgeon Expectations Prior to Anterior Cruciate Ligament Reconstruction

BACKGROUND

When discussing potential treatment with patients choosing to undergo surgery for disruption of the anterior cruciate ligament (ACL) and their families, surgeons spend considerable time discussing expectations of the short- and long-term health of the knee. Most of the research examining patient expectations in orthopedic surgery has focused largely on arthroplasty.

QUESTIONS/PURPOSES

The purpose of this study was to quantitatively assess the differences between the patient's and the surgeon's expectations before primary anterior cruciate ligament reconstruction (ACLR).

METHODS

In this case series, we prospectively enrolled 93 patients scheduled for primary ACLR between 2011 and 2014. Expectations were measured using the Hospital for Special Surgery 23-item Knee Expectations Survey; scores were calculated for each subject.

RESULTS

In all but six categories, patients had expectations that either aligned with their surgeons' or were lower. The largest discordance between surgeon and patient expectations in which the patient had lower expectations was employment; 75% of patients had similar expectations to the surgeon when asked if the knee would be "back to the way it was before the problem started," less than 1% had higher expectations, and 17% had lower expectations.

CONCLUSION

In general, patient expectations align well with surgeon expectations. Patients who are older, have a lower activity level, and who have selected allograft over autograft for ACLR could also be at risk for greater discordance. Understanding these differences, and their predictors, will help guide physicians when they are counseling patients about ACLR and also help them interact with patients after surgery as they assess outcomes.

Influence of Diagnosis and Other Factors on Patients' Expectations of Foot and Ankle Surgery

BACKGROUND

Many patient factors have been associated with higher or lower expectations of orthopedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients' preoperative expectations of elective foot and ankle surgery.

METHODS

Two hundred seventy-eight patients undergoing elective foot or ankle surgery for 1 of 7 common diagnoses were enrolled in a prospective cohort study. Preoperative expectations were assessed with the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed the Foot & Ankle Outcome Score, Short Form 12, pain visual analog scale, and questionnaires for depressive and anxiety symptoms. Demographic and clinical data were collected. Patient factors and diagnosis were analyzed using multivariate regression analysis to identify independent predictors of higher expectations and determine the effect of diagnosis relative to other patient factors on expectations.

RESULTS

The multivariate regression analysis adjusting for demographics and other clinical characteristics showed that diagnosis contributed the most to the model, accounting for 10.5% of the variation in expectations survey scores. Patients with mid- or hindfoot arthritis ( P < .001), hallux valgus ( P = .001), or hallux rigidus ( P = .005) had lower scores (lower expectations) than those with ankle instability or osteochondral lesion. In the model, female sex ( P = .001), non-Caucasian race ( P = .031), and lower scores on the Foot & Ankle Outcome Score daily activities subscale ( P = .024) were associated with higher scores.

CONCLUSIONS

Diagnosis of ankle instability or osteochondral lesion, female sex, non-Caucasian race, and lower Foot & Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively.

LEVEL OF EVIDENCE

Level II, cross-sectional study.

Heterogeneity of Reporting Outcomes in the Spine Surgery Literature

STUDY DESIGN

Review of spine surgery literature between 2005 and 2014 to assess the reporting of patient outcomes by determining the variability of use of patient outcomes metrics in the following categories: pain and disability, patient satisfaction, readmission, and depression.

OBJECTIVE

Expose the heterogeneity of outcomes reporting and discuss current initiatives to create more homogenous outcomes databases.

SUMMARY OF BACKGROUND DATA

There has been a recent focus on the reporting of quality metrics associated with spine surgery outcomes. However, little consensus exists on the optimal metrics that should be used to measure spine surgery outcomes.

MATERIALS AND METHODS

A PubMed search of all spine surgery manuscripts from January 2005 through December 2014 was performed. Linear regression analyses were performed on individual metrics as well as outcomes categories as a fraction of total papers reviewing surgical outcomes.

RESULTS

Outcomes reporting has increased significantly between January 1, 2005 and December 31, 2014 [175/2871 (6.1%) vs. 764/5603 (13.6%), respectively; P<0.001; R=98.1%]. For the category of pain and disability reporting, Visual Analog Score demonstrated a statistically significant decrease in use from 2005 through 2014 [56/76 (73.7%) vs. 300/520 (57.7%), respectively; P<0.001], whereas Oswestry Disability Index increased significantly in use [19/76 (25.0%) vs. 182/520 (35.0%), respectively; P<0.001]. For quality of life, EuroQOL-5 Dimensions increased significantly in use between 2005 and 2014 [4/23 (17.4%) vs. 30/87 (34.5%), respectively; P<0.01]. In contrast, use of 36 Item Short Form Survey significantly decreased [19/23 (82.6%) vs. 57/87 (65.5%), respectively; P<0.01]. For depression, only the Zung Depression Scale underwent a significant increase in usage between 2005 and 2014 [0/0 (0%) vs. 7/13 (53.8%), respectively; P<0.01].

CONCLUSIONS

Although spine surgery outcome reporting has increased significantly over the past 10 years, there remains considerable heterogeneity in regards to individual outcomes metrics utilized. This heterogeneity makes it difficult to compare outcomes across studies and to accurately extrapolate outcomes to clinical practice.

Patient Factors Associated With Higher Expectations From Foot and Ankle Surgery

BACKGROUND

Few authors have investigated patients' expectations from foot and ankle surgery. In this study, we aimed to examine relationships between patients' preoperative expectations and their demographic and clinical characteristics. We hypothesized that patients with more disability and those with anxiety or depressive symptoms would have greater expectations.

METHODS

All adult patients scheduled for elective foot or ankle surgery by 1 of 6 orthopaedic foot and ankle surgeons were screened for inclusion over 8 months. Preoperatively, all patients completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey in addition to the Foot & Ankle Outcome Score (FAOS), Short Form (SF)-12, Patient Health Questionnaire (PHQ)-8, Generalized Anxiety Disorder 7-item scale (GAD-7), and pain visual analog scale (VAS). The expectations survey contained 23 expectations categories, each with 5 answer choices ranging from "I do not have this expectation" to "complete improvement" expected. It was scored from 0 to 100, with higher scores indicating more expectations. Differences in expectations relating to numerous patient demographic and clinical variables were assessed. In total, 352 patients with an average age of 55 ± 15 (range, 18-86) years were enrolled.

RESULTS

Expectations scores were not related to age ( P = .36). On average, women expected to achieve complete improvement more often than men ( P = .011). Variables that were significantly associated with higher expectations scores ( P < .05) included nonwhite race, use of a cane or other assistive device, and greater medical comorbidity. Worse function and quality of life (as assessed by all FAOS subscales and the SF-12 physical and mental components), more depressive and anxiety symptoms, and higher pain VAS scores were associated with higher expectations scores and more expectations ( P < .01 for all).

CONCLUSIONS

The results of this study may help inform surgeons' preoperative discussions with their patients regarding realistic expectations from surgery. Generally, patients with worse function and more disability had higher expectations from surgery. Addressing these patients' expectations preoperatively may help improve their ultimate satisfaction with surgery.

LEVEL OF EVIDENCE

Level II, cross sectional study.

Development of an Expectations Survey for Patients Undergoing Foot and Ankle Surgery

BACKGROUND

Many authors have reported on patient satisfaction from foot and ankle surgery, but rarely on expectations, which may vary widely between patients and strongly affect satisfaction. In this study, we aimed to develop a patient-derived survey on expectations from foot and ankle surgery.

METHODS

We developed and tested our survey using a 3-phase process. Patients with a wide spectrum of foot and ankle diagnoses were enrolled. In phase 1, patients were interviewed preoperatively with open-ended questions about their expectations from surgery. Major concepts were grouped into categories that were used to form a draft survey. In phase 2, the survey was administered to preoperative patients on 2 occasions to establish test-retest reliability. In phase 3, the final survey items were selected based on weighted kappa values for response concordance and clinical relevance.

RESULTS

In phase 1, 94 preoperative patients volunteered 655 expectations. Twenty-nine representative categories were discerned by qualitative analysis and became the draft survey. In phase 2, another 60 patients completed the draft survey twice preoperatively. In phase 3, 23 items were retained for the final survey. For retained items, the average weighted kappa value was 0.54. An overall score was calculated based on the amount of improvement expected for each item on the survey and ranged from zero to 100, with higher scores indicating more expectations. For patients in phase 2, mean scores for both administrations were 65 and 66 and approximated normal distributions. The intraclass correlation coefficient between scores was 0.78.

CONCLUSION

We developed a patient-derived survey specific to foot and ankle surgery that is valid, reliable, applicable to diverse diagnoses, and includes physical and psychological expectations. The survey generates an overall score that is easy to calculate and interpret, and thus offers a practical and comprehensive way to record patients' expectations. We believe this survey may be used preoperatively by surgeons to help guide patients' expectations and facilitate shared decision making.

LEVEL OF EVIDENCE

Level II, cross-sectional study.

Measuring Quality of Care with Patient Satisfaction Scores

Quality of care is a multidimensional concept encompassing safety, efficiency, outcomes, and the patient experience. Traditional quality metrics, such as mortality rates, complication rates, and patient-reported outcomes, are time-consuming and cost-consuming to obtain and risk-stratify. The implications of reimbursement related to patient satisfaction and the ease of data collection have contributed to the perception that satisfaction is a global indicator of health-care quality; however, high satisfaction scores are not consistently correlated with traditional outcome and safety indicators. Higher patient satisfaction may be associated with increased costs of care. Costs may be further increased by the implementation of the satisfaction surveys themselves, which can increase imaging studies and prescriptions. Therefore, satisfaction surveys are not appropriate measures of overall quality of care. Accurate assessment of quality requires a multidimensional approach that includes specific measures for each domain.

Fulfillment of patients' expectations of lumbar and cervical spine surgery

BACKGROUND CONTEXT

Fulfillment of expectations is an important outcome of spine surgery.

PURPOSE

The study aimed to compare fulfillment of expectations after surgery with preoperatively stated expectations.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

The sample included patients who had lumbar and cervical spine surgeries.

OUTCOME MEASURES

The outcome measures were self-report valid surveys-[blinded] Lumbar Spine Surgery Expectations Survey and [blinded] Cervical Spine Surgery Expectations Survey-Oswestry Disability Index (ODI), and Neck Disability Index (NDI).

METHODS

Patients preoperatively completed a valid 20-item lumbar or cervical spine surgery Expectations Survey measuring the amount of improvement expected for symptoms, physical function, and mental well-being. Two years postoperatively, patients were asked about fulfillment of each expectation; a proportion was calculated as the amount of improvement received versus the amount of improvement expected. The proportion ranges from 0 (no expectations fulfilled) to 1 (all expectations fulfilled as expected), to >1 (expectations surpassed). Patients also completed the ODI or NDI, as well as questions about 2-year interval events, such as subsequent surgery.

RESULTS

Among the 366 patients who had lumbar surgery, 90% had at least some of their expectations fulfilled (15% expectations surpassed, 9% expectations fulfilled as expected, and 66% expectations fulfilled somewhat) and 10% had none of their expectations fulfilled; the mean proportion of expectations fulfilled was .66. In multivariable analysis, variables that were associated with a lower proportion of expectations fulfilled were more preoperative expectations, not working full-time, previous spine surgery, surgery for more vertebral levels, subsequent spine surgery, and less improvement in pre- to postoperative ODI and pain scores (p≤.05 for all variables). Among the 133 patients who had cervical surgery, 91% had at least some of their expectations fulfilled (23% expectations surpassed, 8% expectations fulfilled as expected, and 60% expectations fulfilled somewhat) and 9% had none of their expectations fulfilled; the mean proportion of expectations fulfilled was .78. In multivariable analysis, variables that were associated with a lower proportion of expectations fulfilled were more preoperative expectations and less improvement in pre- to postoperative NDI and pain scores (p≤.05 for all variables).

CONCLUSIONS

Fulfillment of expectations after spine surgery is associated with multiple pre- and postoperative variables, including the amount of improvement expected preoperatively.

Instruments used in the assessment of expectation toward a spine surgery: an integrative review

OBJECTIVE

To identify and describe the instruments used to assess patients' expectations toward spine surgery.

METHOD

An integrative review was carried out in the databases PubMed, CINAHL, LILACS and PsycINFO.

RESULTS

A total of 4,402 publications were identified, of which 25 met the selection criteria. Of the studies selected, only three used tools that had confirmed validity and reliability to be applied; in five studies, clinical scores were used, and were modified for the assessment of patients' expectations, and in 17 studies the researchers developed scales without an adequate description of the method used for their development and validation.

CONCLUSION

The assessment of patients' expectations has been methodologically conducted in different ways. Until the completion of this integrative review, only two valid and reliable instruments had been used in three of the selected studies.

OBJETIVO

Identificar e descrever os instrumentos usados para avaliar a expectativa dos pacientes diante do tratamento cirúrgico da coluna vertebral.

MÉTODO

Revisão Integrativa realizada nas bases de dados PubMed, CINAHL, LILACS e PsycINFO.

RESULTADOS

Identificamos 4.402 publicações, das quais 25 atenderam aos critérios de seleção. Dos estudos selecionados, apenas em três os autores utilizaram instrumentos que possuíam validade e confiabilidade confirmadas para serem aplicados; em cinco estudos foram utilizados escores clínicos, modificados para a avaliação das expectativas dos pacientes, e em dezessete os pesquisadores elaboraram escalas sem adequada descrição do método usado para o seu desenvolvimento e validação.

CONCLUSÃO

A avaliação das expectativas dos pacientes tem sido metodologicamente conduzida de diferentes maneiras. Até a finalização desta revisão integrativa, apenas dois instrumentos, válidos e confiáveis, haviam sido utilizados em três dos estudos selecionados.

Proportion of Expectations Fulfilled: A New Method to Report Patient-centered Outcomes of Spine Surgery

STUDY DESIGN

Prospective lumbar and cervical surgery cohorts.

OBJECTIVE

Compare fulfillment of expectations with traditional global outcomes and provide evidence for its validity.

SUMMARY OF BACKGROUND DATA

New lumbar and cervical spine surgery Expectations Surveys can be used to measure fulfillment of expectations and their performance should be compared with existing outcomes.

METHODS

Three hundred thirty-six lumbar and 133 cervical spine surgery patients preoperatively completed valid 20-item Expectations Surveys measuring symptoms, function, and psychological well-being. Approximately 2 years postoperatively patients rated how much improvement they received for each item. The proportion of expectations fulfilled was compared with traditional outcomes, including global satisfaction and change in standard spine questionnaires, with correlation coefficients (r) and areas under receiver operator characteristic curves (AUC).

RESULTS

Ninety percent of lumbar patients had some expectations fulfilled (24% had all expectations fulfilled completely or exceeded). The mean proportion of expectations fulfilled was 0.66 and was associated with satisfaction (r = 0.73 (95% CI 0.68-0.78); AUC = 0.92 (95% CI 0.89-0.95) (P < 0.0001)). Based on the association with satisfaction, a clinically important proportion of expectations fulfilled for lumbar surgery is approximately 0.60 (sensitivity 0.90, specificity 0.79).Ninety-one percent of cervical patients had some expectations fulfilled (31% had all expectations fulfilled completely or exceeded). The mean proportion of expectations fulfilled was 0.78 and was associated with satisfaction (r = 0.62 (95% CI 0.50-0.72); AUC = 0.92 (95% CI 0.87-0.97) (P < 0.0001)). Based on the association with satisfaction, a clinically important proportion of expectations fulfilled for cervical surgery is approximately 0.62 (sensitivity 0.91, specificity 0.80).

CONCLUSION

The proportion of expectations fulfilled is a new patient-centered outcome that measures results of spine surgery. Unique features of this novel outcome are that it requires prospectively acquired pre- and postoperative data, provides details about in what ways patients believe surgery did and did not meet goals, and offers surgeons opportunities to address unfilled expectations directly.

LEVEL OF EVIDENCE

1.