Development and testing of an expectations survey for patients undergoing lumbar 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.

Associations between surgeons' preoperative expectations of lumbar surgery and patient-reported 2-year outcomes

PURPOSE

Surgeons' preoperative expectations of lumbar surgery may be associated with patient-reported postoperative outcomes.

METHODS

Preoperatively spine surgeons completed a validated Expectations Survey for each patient estimating amount of improvement expected (range 0-100). Preoperative variables were clinical characteristics, spine-specific disability (ODI), and general health (RAND-12). Two years postoperatively patients again completed these measures and global assessments of satisfaction. Surgeons' expectations were compared to preoperative variables and to clinically important pre- to postoperative changes (MCID) in ODI, RAND-12, and pain and to satisfaction using hierarchical models.

RESULTS

Mean expectations survey score for 402 patients was a 57 (IQR 44-68) reflecting moderate expectations. Lower scores were associated with preoperative older age, abnormal gait, sensation loss, vacuum phenomena, foraminal stenosis, prior surgery, and current surgery to more vertebrae (all p ≤ .05). Lower scores were associated postoperatively with not attaining MCID for the ODI (p = .02), RAND-12 (p = .01), and leg pain (p = .01). There were no associations between surgeons' scores and satisfaction (p = .06-.27). 55 patients (14%) reported unfavorable global outcomes and were more likely to have had fracture/infection/repeat surgery (OR 3.2, CI 1.6-6.7, p = .002).

CONCLUSION

Surgeons' preoperative expectations were associated with patient-reported postoperative improvement in symptoms and function, but not with satisfaction. These findings are consistent with clinical practice in that surgeons expect some but not complete improvement from surgery and do not anticipate that any particular patient will have markedly unfavorable satisfaction ratings. In addition to preoperative discussions about expectations, patients and surgeons should acknowledge different types of outcomes and address them jointly in postoperative discussions.

Introducing the New Patient Expectations in Spine Oncology Questionnaire

BACKGROUND AND OBJECTIVES

It has been hypothesized that a discrepancy between pretreatment expectations and perceived outcomes is a significant source of patient dissatisfaction. Currently, there is lack in understanding and tools to assess patient expectations regarding the outcomes of treatment for spinal metastases. The objective of this study was therefore to develop a patient expectations questionnaire regarding the outcomes after surgery and/or radiotherapy for spinal metastases.

METHODS

A multiphase international qualitative study was conducted. Phase 1 of the study included semistructured interviews with patients and relatives to understand their expectations of the outcomes of treatment. In addition, physicians were interviewed about their communication practices with patients regarding treatment and expected outcomes. In phase 2, items were developed based on the results of the interviews in phase 1. In phase 3, patients were interviewed to validate the content and language of the questionnaire. Selection of the final items was based on feedback from patients regarding content, language, and relevance.

RESULTS

In phase 1, 24 patients and 22 physicians were included. A total of 34 items were developed for the preliminary questionnaire. After phase 3, a total of 22 items were retained for the final version of the questionnaire. The questionnaire is divided into 3 sections: (1) patient expectations regarding treatment outcomes, (2) prognosis, and (3) consultation with the physician. The items cover expectations related to pain, analgesia requirements, daily and physical function, overall quality of life, life expectancy, and information provided by the physician.

CONCLUSION

The new Patient Expectations in Spine Oncology questionnaire was developed to evaluate patient expectations regarding the outcomes after treatment for spinal metastases. The Patient Expectations in Spine Oncology questionnaire will allow physicians to systematically assess patient expectations of planned treatment and thus help guide patients toward realistic expectations of treatment outcome.

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.

A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction

STUDY DESIGN

Qualitative interview study.

OBJECTIVE

The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction.

SUMMARY OF BACKGROUND DATA

Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery.

MATERIALS AND METHODS

Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed.

RESULTS

A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences.

CONCLUSION

Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Emerging Need for PROMs to Measure the Impact of Spine Disorders on Overall Health and Well-being: Measuring Expectations as an Example for Lumbar Degenerative Spondylolisthesis

Background: Assessing the impact of spine disorders such as lumbar degenerative spondylolisthesis (LDS) on overall health is a component of quality of care that may not be comprehensively captured by spine-specific and single-attribute patient-reported outcome measures (PROMs). Purpose: We sought to compare PROMs to the Lumbar Surgery Expectations Survey ("Expectations Survey"), which addresses multiple aspects of health and well-being, and to compare the relevance of surgeon-selected versus survey-selected Patient-Reported Outcomes Measurement Information System (PROMIS) items to LDS. Methods: In a cross-sectional study, 379 patients with LDS preoperatively completed the Expectations Survey, Numerical Rating Pain Scales, Oswestry Disability Index (ODI), and PROMIS computer-adaptive physical function, pain, and mental health surveys. Expectations Survey scores were compared to PROMs with correlation coefficients (indicating strengths of relationships) and probability values (indicating associations by chance). Surgeons reviewed physical function questions to identify those particularly relevant to LDS. Results: Patients' mean age was 67 years, 64% were women, and 83% had single-level and 17% had multiple-level LDS. Probability values between the Expectations Survey and PROMs were reliable, but strengths of relationships were only mild to moderate, indicating PROMs did not comprehensively capture the impact of LDS. None of the surgeon-selected PROMIS physical function questions were posed to patients. Conclusion: This cross-sectional study found PROMs to be reliably associated but not strongly correlated with the Expectations Survey, which addresses the whole-patient impact of LDS. New measures that complement PROMIS and ODI should be developed to capture the whole-person effects of LDS and permit attribution of LDS treatments to overall health.

High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis

BACKGROUND CONTEXT

Fulfillment of expectations is a patient-centered outcome that has not been assessed based on fusion status for lumbar degenerative spondylolisthesis (LDS).

PURPOSE

To compare preoperatively cited expectations and 2-year postoperative fulfillment of expectations between patients undergoing decompression alone (no-fusion) vs. decompression plus fusion (fusion) for LDS.

STUDY DESIGN

Longitudinal cohort.

PATIENT SAMPLE

357 patients.

OUTCOME MEASURES

Postoperative version of Lumbar Spine Surgery Expectations Survey, Oswestry Disability Index (ODI), satisfaction with surgery.

METHODS

Preoperatively patients completed the 20-item Expectations Survey measuring amount of 'improvement expected' for symptoms, physical function, and psychosocial well-being (score range 0-100); two years postoperatively patients completed the follow-up Survey measuring 'improvement received'. The proportion of expectations fulfilled was calculated as 'improvement received' divided by 'improvement expected' (<1 some expectations fulfilled, >1 expectations surpassed). Patients also completed the ODI, SF-12 mental health subscale, satisfaction with surgery, and measures of comorbidity and psychosocial status, including social support (i.e. help at home) and prior orthopedic surgery (i.e. hip/knee arthroplasty).

RESULTS

Patients' mean age was 67 years, 61% were women, 82% had single-level LDS, 73% had fusion, and mean follow-up was 26.2 months. Compared to patients with no-fusion, patients with fusion had more pain, spinal instability, use of opioids, disability, and greater preoperative Expectations Survey scores (69 vs 74, p=.008). The proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 vs. .79, p=.40), but more variable for fusion (IQR .32 vs. .40). In multivariable analysis with the proportion as the dependent variable, fulfilled expectations was associated with better mental well-being (coeff=1.1, 95% CI 0.6-1.7, p=.0001) and more social support (coeff=3.3, 95% CI 1.1-5.6, p=.004) and unfulfilled expectations was associated with prior arthroplasty (coeff=-8.6, 95% CI -15.4-(-1.9), p=.01) and subsequent lumbar surgery (coeff=-15.6, 95% CI -25.2-(-6.0), p=.002). Similar associations were found for change in ODI and satisfaction.

CONCLUSIONS

Patients had high preoperative expectations of surgery with greater expectations for decompression-fusion compared to decompression-alone. Although more variable for the fusion group, both groups had high proportions of expectations fulfilled. This study highlights the spectrum of clinical and psychosocial variables that impacts fulfillment of expectations for both decompression-alone and decompression-fusion for LDS surgery.

Reliability and Validity of Adapted Russian Version of Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey

Background: Patients' expectations are an important determinant in their decision to undergo lumbar spinal surgery-particularly their expectations of recovery after surgery. The Hospital for Special Surgery Lumbar Spine Surgery Expectations Survey (HSS-LSSES) is one tool used to assess this; however, the original version was only available in English. Objective: We sought to evaluate the reliability and validity of a translated and adapted Russian-language version of the HSS-LSSES. Methods: This was a prospective study of 91 patients with degenerative disc disease who underwent lumbar spine surgery with instrumented fixation at a single institution in Saint Petersburg, Russia. Patients were recruited between December 2019 and February 2021 and asked about their expectations of surgery with a translated and adapted Russian version of the HSS-LSSES. To analyze construct validity, participants also completed disease-specific and general quality-of-life scales (Oswestry Disability Index, European Quality of Life-5 Dimensions, and 36-item Short-Form Health Survey). Intraclass correlation coefficients (ICCs; 2-way random effects model, absolute agreement) were used to determine test-retest reliability of the total score of the Russian HSS-LSSES. Internal consistency was evaluated through the estimation of Cronbach's alpha between the test and retest response of the questionnaire. Results: The test-retest stability of the Russian HSS-LSSES evaluated through the estimation of ICC was found to have good stability. The instrument was shown to have high internal consistency. Conclusion: This study demonstrates that a translated and adapted Russian version of HSS-LSSES had good internal consistency, reliability, construct validity, and no floor and ceiling effects. Therefore, we recommend its use as a tool for evaluating Russian-speaking patients' expectations before lumbar spine surgery.

Editorial Commentary: Assessing Outcomes in Terms of Fulfillment of Patient Expectations Is Complementary to Traditional Measures Including Satisfaction

The topic of patients' expectations is receiving increasing attention as a patient-centered variable in preoperative orthopaedic assessment. Formally querying patients about expectations is necessary because surgeons may not be aware of these expectations, which often derive from multiple sources outside encounters with surgeons. Validated patient-derived surveys now exist for diverse orthopaedic surgeries to preoperatively measure expectations for improvement in symptoms and physical and psychological well-being. Assessing results of surgery in terms of fulfillment of these expectations is a patient-centered outcome that complements traditional measurements of satisfaction and pre- to postoperative change in symptoms and function. Validated follow-up surveys also now exist that ask patients for each item they expected before surgery, how much improvement have they actually received after surgery. The amount of improvement expected versus the amount of improvement received constitutes a measure of fulfilled expectations. The advantages of fulfillment of expectations as an outcome are that it prospectively includes both pre- and postoperative patients' perspectives and, because it is composed of multiple items, it can identify which symptoms and functions have improved to expected levels and which have not, thus providing the rationale for why patients rate outcomes the way they do. Therefore, measured in this way, postoperative fulfillment of expectations is a unique and novel patient-centered assessment for the comprehensive evaluation of orthopaedic surgical outcomes.

Low Back Pain Versus Back-Related Leg Pain: How Do Patient Expectations and Outcomes of Lumbar Spine Surgery Compare?

Background: An increasing number of lumbar spine conditions are treated surgically. Such intervention, however, is commonly thought to be more effective in addressing leg pain than low back pain. Patient expectations may also contribute to self-reported surgical outcomes. Questions/Purposes: We sought to compare the expectations of patients in 2 groups undergoing lumbar spine surgery: those with predominantly low back pain and those with predominantly leg pain. We also sought to evaluate how these expectations were fulfilled for each group. Methods: We carried out a retrospective analysis of prospectively collected data from a prior study in which patients scheduled for lumbar spine surgery at a single institution completed validated surveys preoperatively and at 2 years postoperatively, including a 20-item survey on expectations for lumbar spine surgery. The patients were enrolled in the study between February 2010 and August 2012, and were divided into 2 cohorts: a "Back > Leg" group that consisted of patients with back pain that was isolated or greater than leg pain, and a "Leg ≥ Back" group that consisted of patients with leg pain that equaled or exceeded back pain. The primary analysis compared composite expectation scores (range, 0-100) between groups. Results: A total of 366 patients were deemed eligible for the study; of these, 162 patients were allocated to the Back > Leg group and 204 patients were allocated to the Leg ≥ Back group. Patients in the Leg ≥ Back group had a greater mean preoperative expectation score compared with those in the Back > Leg group. Multivariate analysis demonstrated that higher preoperative expectations were associated with leg pain symptoms after controlling for disease diagnosis. Both groups reported similar proportions of fulfilled expectations. Conclusion: Patients with predominantly leg pain hold greater preoperative expectations for lumbar spine surgery than do patients with predominantly back pain. That these patient groups reported similar fulfillment of their expectations at 2 years postoperatively illustrates the greater clinical outcomes achieved among patients who presented with predominantly leg pain.

Concordance Between Patients' and Surgeons' Expectations of Lumbar Surgery

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

The aims of this study were to measure concordance between patients' and surgeons' preoperative expectations of lumbar surgery, and determine which member of the dyad more closely predicted fulfillment of expectations, defined as patient-reported status postoperatively.

SUMMARY OF BACKGROUND DATA

Concordant patient-surgeon expectations reflect effective communication and should foster better outcomes.

METHODS

Preoperatively patients and surgeons completed identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function. Responses ranged from "complete improvement" to "do not have this expectation"; scores for each survey ranged from 0 to 100 (greatest expectations). Concordance between pairs of patient-surgeon scores was measured with the intraclass correlation coefficient (ICC). Postoperatively, fulfillment of expectations was measured from patient-reported amount of improvement received and was calculated as the proportion of patient-reported postoperative score relative to patient-reported preoperative score, and surgeon-reported preoperative score (range 0 [no expectations fulfilled] to >1.2 [expectations surpassed]). Clinical measures included patient-reported spine-related disability.

RESULTS

For 402 patient-surgeon pairs, mean survey scores were 73 ± 19 (patients) and 57 ± 16 (surgeons); 84% of patients had higher scores than surgeons, mainly due to expecting complete improvement, whereas surgeons expected a lot/moderate/little improvement. The ICC for the entire sample was .31 (fair agreement); for subgroups, the greatest difference in ICC was for patients with more spine-related disability (ICC = .10, 95% confidence interval [CI]:0.00-0.23) versus less disability (ICC = .46, 95% CI: 0.34-0.56). 96% of patients were contacted ≥2.0 years postoperatively. Proportions of expectations fulfilled were 0.79 (0-3.00) (patients) and 1.01 (0-2.29) (surgeons). Thus patients were less likely to anticipate subsequent postoperative status (odds ratio [OR] 0.34, 95% CI 0.25-0.45) versus surgeons who were more likely to anticipate patient-reported postoperative status (OR 2.98, 95% CI: 2.22-4.00).

CONCLUSION

Concordance between patients' and surgeons' expectations was fair; due mostly to patients expecting complete improvement whereas surgeons expected a lot/moderate/little improvement. Compared to patients' expectations, surgeons' expectations more closely coincided with patient-reported fulfillment of expectations 2 years postoperatively.Level of Evidence: 1.

Unfulfilled Expectations After Surgery for Adult Lumbar Scoliosis Compared with Other Degenerative Conditions

BACKGROUND

Patients' expectations influence their decisions to undergo surgery for scoliosis, and fulfillment of expectations is an important patient-centered outcome.

QUESTIONS/PURPOSES

In a 2-year cohort study, we compared the proportion of expectations fulfilled based on the number of vertebrae involved in surgery between adult lumbar scoliosis patients and controls with other degenerative conditions.

METHODS

Patients pre-operatively completed a valid lumbar surgery expectations survey addressing expected improvements for symptoms, function, and psychosocial well-being (scores from 0 to 100; higher score indicates more expectations). Two years post-operatively, the patients completed another survey, this one recording how much improvement they actually experienced; fulfillment was defined as a proportion (i.e., received improvement/expected improvement). The range was 0 (none fulfilled) to > 1 (expectations surpassed). We further analyzed data according to the number of vertebrae involved in the surgery.

RESULTS

We included 42 scoliosis patients and 134 controls with similar mean ages (66 vs 64 years, respectively) and pre-operative expectations survey scores (72 vs 70, respectively). When we stratified by < 3 or ≥ 3 vertebrae, we found that the proportion of expectations fulfilled differed for scoliosis patients but not for controls. In multivariable analysis, lower proportion of expectations fulfilled was associated with greater pre-operative expectations, less improvement in pre- to post-operative disability, and the composite interaction of scoliosis and number of vertebrae.

CONCLUSIONS

Compared with controls, scoliosis patients who required surgery to a greater number of vertebrae were more likely to have unfulfilled expectations 2 years post-operatively. Our findings support the importance of addressing expectations pre-operatively with all patients, especially those with scoliosis who require surgery to ≥ 3 vertebrae.

Expectations of Lumbar Surgery Outcomes among Opioid Users Compared with Non-Users

STUDY DESIGN

Matched cohort study.

PURPOSE

To compare and describe the effect of opioid usage on the expectations of lumbar surgery outcomes among patients taking opioids and patients not taking opioids.

OVERVIEW OF LITERATURE

Chronic opioid use is common among lumbar-spine surgery patients. The decision to undergo elective lumbar surgery is influenced by the expected surgery outcomes. However, the effects of opioids on patients' expectations of lumbar surgery outcomes remain to be rigorously assessed.

METHODS

A total of 77 opioid users grouped according to dose and duration (54 "higher users," 30 "lower users") were matched 2:1 to 154 non-opioid users based on age, sex, marital status, chiropractic care, disability, and diagnosis. All patients completed a validated 20-item Expectations Survey measuring expected improvement with regard to symptoms, function, psychological well-being, and anticipated future spine condition. "Greater expectations" was defined as a higher survey score (possible range, 0-100) based on the number of items expected and degree of improvement expected.

RESULTS

The mean Expectations Survey scores for all opioid users and all non-users were similar (73 vs. 70, p=0.18). Scores were different, however, for lower users (79) compared with matched non-users (69, p=0.01) and compared with higher users (70, p=0.01). In multivariable analysis, "reater expectations" was independently associated with having had chiropractic care (p=0.03), being more disabled (p=0.002), and being a lower-dose opioid user (p=0.03). Compared with higher users, lower users were also more likely to expect not to need pain medications 2 years after surgery (47% vs. 83%, p=0.003).

CONCLUSIONS

Patient expectations of lumbar surgery are associated with diverse demographic and clinical variables. A lower dose and shorter duration of opioid use were associated with expecting more items and expecting more complete improvement compared with non-users. In addition, lower opioid users had greater overall expectations compared with higher users.

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Reconstruction Preoperative Expectations Survey

INTRODUCTION

Understanding and meeting the patients' preoperative expectations for anterior cruciate ligament (ACL) reconstruction (ACLR) is critical for achieving successful patient-centered outcomes. There is currently no standardized method to assess preoperative expectations of ACLR based on the patient-derived methods. The purpose of this study was to develop and test a patient-derived patient expectations survey specific to primary ACLR. We hypothesized that a valid and reliable patient-derived survey could be developed to measure these expectations and that patients would have diverse expectations before surgery.

METHODS

The Hospital for Special Surgery ACL-expectation score was developed through a four-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation. Seventy-two patients were involved in the development phase, and 80 patients were included in the validation phase. Discriminant validity testing was performed regarding age and sex. Cronbach alpha was calculated to assess the internal consistency of responses in the survey.

RESULTS

The final survey instrument consisted of 10 questions scored on a visual analog scale from 1 to 10, for a maximum score of 50 points. No statistically significant differences were observed in the score between men and women (P = 0.517) nor between age quartiles (P = 0.807). No statistically significant difference was observed in the scores when each sex was stratified by age quartile (P = 0.275 for men, P = 0.878 for women). Cronbach alpha for all items was 0.745, indicating excellent internal consistency. The intraclass correlation coefficient for test-retest reliability was 0.774, indicating a strong correlation.

CONCLUSION

The Hospital for Special Surgery ACL-expectations score is a patient-derived, tested and reliable preoperative expectations measure with excellent psychometrics for active adults undergoing ACLR. We suggest future clinical studies in ACLR to incorporate this tool as a preoperative measure of patient expectations.

Characterizing patients' expectations in hip and knee osteoarthritis

PURPOSE

Previous research reported conflicting findings regarding the association of sociodemographic and clinical variables with expectations for surgical outcomes. The current study aimed to identify and characterize different subgroups of osteoarthritis patients with respect to amount and level of expectations, and to examine factors that are associated with expectations.

METHODS

Hip and knee patients (n = 287) completed a questionnaire 1 week post consultation. Linear regression analyses were performed to examine whether sociodemographic (e.g., age, sex) and clinical factors (e.g., pain, function) were associated with expectations. Latent class analysis (LCA) was used to identify different subgroups and the step 3 method was conducted to assess subgroup characteristics.

RESULTS

Mean age of patients was 70 years (SD = 8) and 57% of patients was female. Most improvement was expected in walking ability and pain relief. Higher expectations were associated with younger age, male sex, and functional disability. Both hip and knee patients could be classified into three subgroups. These subgroups differed significantly on pain and other symptoms, and functional disability.

CONCLUSION

Both hip and knee patients reported pain and other osteoarthritis symptoms and functional disability and consequently had high expectations in these areas for treatment outcomes. Higher expectations were characterized by more pain, more symptoms and more functional disability. These insights could guide physicians in the discussion of expectations during consultation.

Fulfillment of Expectations After Orthopedic Foot and Ankle Surgery

BACKGROUND

To date, no study has assessed fulfillment of patients' expectations after foot and ankle surgery. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively.

METHODS

Preoperatively, patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), to between 0 and 1 (expectations partially fulfilled), to 1 (expectations met), to greater than 1 (expectations surpassed). Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) with 95% confidence intervals (CIs) were used to compare the expectations survey to other outcome surveys, including Foot and Ankle Outcome Score, improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction.

RESULTS

Of the 271 patients (mean age 55.4 years, mean BMI 27.5, 65% female), 34% had expectations surpassed (FP >1), 4% had expectations met, 58% had expectations partially fulfilled (FP between 0 and 1), and 5% had no expectations met. The mean FP was 0.84 ± 0.41 (range 0-3.13), indicating partially fulfilled expectations. FP correlated significantly with all outcome measures (P ≤ .007). FP was associated most closely with satisfaction (r = 0.66 [95% CI 0.57-0.75]; AUC = 0.92 [95% CI 0.88-0.96]; P < .001) and improvement (r = 0.73 [95% CI 0.64-0.81]; AUC = 0.94 [95% CI 0.91-0.96]; P < .001). Based on the associations with satisfaction and improvement outcomes, a clinically important proportion of expectations fulfilled is 0.68, with sensitivity 0.85-0.90 and specificity 0.84-0.86.

CONCLUSION

The proportion of expectations fulfilled is a novel patient-centered outcome that correlated with validated outcome measures. The expectations survey may be used by surgeons to counsel patients preoperatively and also to assess patients' results postoperatively.

LEVEL OF EVIDENCE

Level II, prospective comparative series.

Positive and negative work events attributed to the spine 2 years after lumbar surgery among patients working preoperatively

OBJECTIVE

Return to work after lumbar surgery is not synonymous with effective job performance, and it is likely that patients who undergo spine surgery experience both positive and negative events attributable to their spine after returning to work. The authors' objectives were to measure work events attributable to the spine during the 2 years after lumbar surgery and to assess associated demographic and clinical characteristics.

METHODS

Employed patients scheduled for lumbar surgery were interviewed preoperatively and reported work characteristics, including amount of improvement in job performance that they expected from surgery. Clinical variables, such as comorbidities and surgical complexity, were collected using standard scales. Two years postoperatively patients completed the 22-item work domain of the Psychiatric Epidemiological Research Interview Life Events Scale (PERI) asking about major positive and negative events attributable to the spine that occurred since surgery. Event rates were assessed with logistic regression. Patients also reported the amount of improvement obtained in job performance, which was compared to the amount of improvement expected in bivariate analyses.

RESULTS

Two hundred seven working patients (mean age 53 years, 62% men) were interviewed preoperatively. At 2 years after surgery, 86% were working and 12% reported negative events attributable to the spine (e.g., reduced workload, retirement). In multivariable analysis, high school education or less (OR 4.6, CI 1.7-12.3, p = 0.003), another spine surgery (OR 3.4, CI 1.2-10.1, p = 0.03), and new/worse comorbidity (OR 3.3, CI 1.2-8.8, p = 0.02) remained associated. Seven percent reported positive events attributable to the spine; not having postoperative complications was associated (OR 24, CI 4-156, p = 0.001). Of 162 patients queried preoperatively about expectations, 120 expected improvement in work; postoperatively, 82% reported some improvement (42% reported less improvement than expected and 40% as much as or more improvement than expected), 18% reported no improvement. No improvement was associated with less education (OR 1.5, CI 1.0-2.1, p = 0.04), older age (OR 1.1, CI 1.0-1.1, p = 0.005), more complex surgery (OR 1.1, CI 1.0-1.1, p = 0.07), and another spine surgery (OR 6.1, CI 1.9-19.8, p = 0.003). In descriptive analyses for another sample of preoperatively work-disabled patients, most had physically demanding jobs and only 33% returned to work postoperatively.

CONCLUSIONS

Most preoperatively working patients were working postoperatively, reported spine-related improvement in job performance, and reported the occurrence of both positive and negative work events attributable to the spine. This study proposes novel work outcomes (i.e., positive and negative work events) and potential methods to measure them.

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.

Sources of Patients' Expectations of Lumbar Surgery

STUDY DESIGN

A cross-sectional, mixed methods analysis of sources of expectations of lumbar surgery.

OBJECTIVE

The aim of this study was to ascertain sources of expectations and compare them to clinical characteristics.

SUMMARY OF BACKGROUND DATA

Understanding where patients obtain expectations of lumbar surgery is necessary in order to develop interventions to foster appropriate expectations.

METHODS

This was a qualitative-quantitative study of 428 patients interviewed preoperatively with a 20-item validated survey, which asks patients how much improvement they expect per item. Patients then were asked open-ended questions about how they came to have these expectations and, using qualitative analysis, responses were grouped into themes representing different sources of expectations. The likelihood of citing various sources was then assessed with odds ratios (ORs) based on demographic and clinical characteristics.

RESULTS

Patients' mean age was 55 years, 80% had degenerative diagnoses and 24% had prior lumbar surgery. Patients volunteered multiple sources; most prevalent were current surgeon (83%), internet resources (55%), social network contacts (26%), other physicians (22%); and previous experience (65%) for the subgroup who had prior lumbar surgery. Patients were more likely to cite their surgeon if they had less disability [OR 2.8, confidence interval (CI) 1.3-5.8, P = 0.007], were treated with conservative care, such as physical therapy (OR 2.7, CI 1.6-4.7, P = 0.0003), and had symptoms for ≤12 months (OR 1.8, CI 1.1-3.0, P = 0.03). Patients who cited the internet were employed (OR 2.2; CI 1.5-3.3; P < 0.0001), were treated with physical therapy (OR 1.9; CI 1.2-3.1; P = 0.006), had a negative screen for depression (OR 1.8; CI 1.2-2.8; P = 0.004), and were younger (OR 1.6; CI 1.1-2.4; P = .02). Patients were less likely to expect complete improvement for most items of the survey if they had prior lumbar surgery (P = 0.002) or other orthopedic surgery (P = 0.02).

CONCLUSION

Patients derive their expectations of lumbar surgery from multiple sources. Some sources are modifiable through enhanced communication with surgeons and potentially through novel modes of education, such as web-based resources that are specifically designed to address expectations.

LEVEL OF EVIDENCE

2.

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.

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.

HSS Dysphagia and Dysphonia Inventory (HSS-DDI) Following Anterior Cervical Fusion: Patient-Derived, Validated, Condition-Specific Patient-Reported Outcome Measure Outperforms Existing Indices

BACKGROUND

Dysphagia and dysphonia are common complications after anterior cervical spine surgery; however, reported prevalences vary greatly due to a lack of reliable clinical standards for measuring postoperative swallowing and speech dysfunction. The Hospital for Special Surgery Dysphagia and Dysphonia Inventory (HSS-DDI) was developed as a patient-derived, patient-reported instrument to measure dysphagia and dysphonia more accurately after anterior cervical spine surgery than existing indices.

METHODS

This multiphase survey-development study implemented a mixed-methods approach. Phase 1 involved qualitative assessment of postoperative patient-reported swallowing or speaking deficiencies to assemble a draft survey. Phase 2 established test-retest reliability and finalized the 31-item HSS-DDI. Phase 3 compared the HSS-DDI with the Swallowing-Quality of Life (SWAL-QOL) questionnaire and the M.D. Anderson Dysphagia Inventory (MDADI) for validity and responsiveness.

RESULTS

Phase 1, performed to formulate the draft survey, included 25 patients who were asked about speech and swallowing dysfunction after anterior cervical spine surgery involving at least 3 vertebral levels. Phase 2 included 49 patients who completed the draft survey twice. The mean scores (and standard deviation) for each administration of the HSS-DDI were 67 ± 24 and 75 ± 22, the Cronbach alpha coefficients were both 0.97, and the intraclass correlation coefficient was 0.80. The 31-item HSS-DDI was finalized with all but 2 items having weighted kappa values of ≥0.40. Phase 3 included 127 patients and established external validity, with most correlation coefficients between the HSS-DDI and the SWAL-QOL and MDADI ranging from 0.5 to 0.7. Internal validity was established by identifying worsening HSS-DDI scores with increases in the number of vertebral levels involved (p = 0.02) and in the Surgical Invasiveness Index (p = 0.006). HSS-DDI responsiveness ascertained by effect size (0.73) was better than that of the SWAL-QOL and MDADI. The average administration time for the HSS-DDI was 2 minutes and 25 seconds.

CONCLUSIONS

The HSS-DDI is efficient, valid, and more responsive to change after anterior cervical spine surgery than existing surveys.

CLINICAL RELEVANCE

The HSS-DDI fills a gap in postoperative assessment by providing a reliable, more clinically sensitive, patient and condition-specific evaluation of dysphagia and dysphonia prospectively and longitudinally.

Successful lumbar surgery results in improved psychological well-being: a longitudinal assessment of depressive and anxiety symptoms

BACKGROUND CONTEXT

Preoperative psychological symptoms predict surgical outcomes. The impact of surgical outcomes on psychological well-being, however, has not been delineated.

PURPOSE

This study aimed to compare pre- with postoperative depressive and anxiety symptoms based on success of surgery, defined as fulfilled expectations and improvement in disability and pain.

STUDY DESIGN/SETTING

A prospective 2-year longitudinal study in a tertiary care center was carried out.

PATIENT SAMPLE

The sample consisted of 276 patients who underwent lumbar surgery.

OUTCOME MEASURES

The Geriatric Depression Scale (GDS) and the Spielberger State-Trait Anxiety Inventory (STAI) were the outcome measures.

METHODS

Patients completed the following validated surveys several days before and again 2 years after surgery: the GDS with a set threshold for a positive screen for depression; the STAI with population norms used as threshold values; the Oswestry Disability Index (ODI); a numerical pain rating; and the Expectations Survey measuring amount of improvement expected. Dependent variables were pre- to postoperative within-patient change in GDS and STAI scores. Independent variables were three outcomes of surgery: proportion of expectations fulfilled, and changes in ODI scores and pain ratings. Analyses were conducted with GDS and STAI scores as continuous variables and according to threshold values, and for expectations, ODI and pain according to minimum clinically important differences (MCIDs).

RESULTS

Mean age was 55, 56% were men, and 78% had degenerative diagnoses. For depressive symptoms, 41% screened positive preoperatively and 16% screened positive postoperatively; 72% had some improvement. In multivariable analysis adjusted for age, gender, comorbidity, diagnosis, and surgical invasiveness, depressive symptoms improved more for more expectations fulfilled (p<.0001), more ODI improvement (p<.0001), and more pain improvement (p=.001). For anxiety symptoms: 59% were worse than population norms preoperatively and 26% were worse postoperatively; 73% had some improvement. In adjusted multivariable analyses, anxiety symptoms improved more for more expectations fulfilled (p=.0002), more ODI improvement (p<.0001), and more pain improvement (p=.03). Similar results were obtained according to threshold values and MCIDs.

CONCLUSION

Substantial improvements in psychological well-being resulted after surgery among patients with favorable spine-specific outcomes.

Improvement in Pain After Lumbar Spine Surgery: The Role of Preoperative Expectations of Pain Relief

OBJECTIVES

Improvement in pain is a major expectation of patients undergoing lumbar spine surgery.

MATERIALS AND METHODS

Among 422 patients, the goal of this prospective study was to measure 2-year postoperative pain and to determine whether this outcome varied according to patient and clinical characteristics, including amount of pain relief expected preoperatively. Before surgery patients completed valid questionnaires that addressed clinical characteristics and expectations for pain improvement. Two years after surgery patients reported how much pain improvement they actually received.

RESULTS

The mean age was 56 years old and 55% were men. Two years after surgery 11% of patients reported no improvement in pain, 28% reported a little to moderate improvement, 44% reported a lot of improvement, and 17% reported complete improvement. In multivariable analysis, patients reported less pain improvement if, before surgery, they expected greater pain improvement (odds ratio [OR] 1.4), had a positive screen for depression (OR 1.7), were having revision surgery (OR 1.6), had surgery at L4 or L5 (OR 2.5), had a degenerative diagnosis (OR 1.6), and if, after surgery, they had another surgery (OR 2.8) and greater back (OR 1.3) and leg (OR 1.1) pain (all variables P≤0.05).

CONCLUSIONS

Pain is not uncommon after lumbar surgery and is associated with a network of clinical, surgical, and psychological variables. This study provides evidence that patients' expectations about pain are an independent variable in this network. Because expectations are potentially modifiable this study supports addressing pain-related expectations with patients before surgery through discussions with surgeons and through formal preoperative patient education.

What Demographic and Clinical Characteristics Correlate With Expectations With Trapeziometacarpal Arthritis?

BACKGROUND

Pretreatment variables have been shown to be associated with the fulfillment of patient expectations, yet in treating thumb trapeziometacarpal osteoarthritis (OA) it remains unclear how patient expectations correlate with the effectiveness of treatment. An increased understanding of the variables that affect patient expectations enables tailored patient education and patient-provider communication.

QUESTIONS/PURPOSES

(1) Is there a correlation between patient demographics and clinical characteristics, and the expectations the patients have when seeking treatment for trapeziometacarpal OA? (2) What factors are independently associated with the total expectations score and frequency of expecting "back to normal" among patients treated for trapeziometacarpal OA?

METHODS

Between March 2011 and October 2013, 89 patients of all 96 eligible patients seeking treatment for trapeziometacarpal OA were approached and agreed to participate in this study. Participants completed a validated expectations survey measuring the number of expectations and the degree of improvement expected. Comparative analysis of demographic and clinical characteristics and multivariate regression analysis against patients' expectations were performed to assess and identify factors that correlate with the number and degree of expectations. Sample size was determined with an a priori power analysis (with 80% power and statistical significance set at p < 0.05), which showed that 88 patients were needed to detect the minimal clinical difference of 12 points in the Michigan Hand Questionnaire; we then increased this by 10% to allow for potential dropouts.

RESULTS

After controlling for potential confounding variables such as age, hand dominance, and work status, the following factors were associated with a higher expectations score: choice of surgery (β = 11.5; 95% CI, 0.7-23.8; p = 0.044), female gender (β = 19.0; 95% CI, 5.3-32.7; p = 0.007), and dominant side affected (β = -41.6; 95% CI, -63.7 to -19.5; p < 0.001). For the frequency of "back to normal" responses, surgical treatment (β = 7.4; 95% CI, 2.3-12.4; p = 0.005) and history of previous injury (β = 8.2; 95% CI, 0.1-16.3; p = 0.047) were independently associated factors after controlling for confounding variables. There were no independent associations with age, marital status, work status, depression or anxiety, or prior contralateral surgery.

CONCLUSIONS

Patients whose dominant side was affected, were female, and chose surgical treatment, had higher total expectations. Patients who reported an antecedent injury and chose surgical treatment more frequently expected a return to normal. With identification of these factors, orthopaedic surgeons can recognize patients who are prone to higher expectations, and, thus, have the opportunity to implement efficient pretreatment education. In addition, identification of specific factors enables a focused measure of the effect of these factors on the fulfillment of expectations.

LEVEL OF EVIDENCE

Level II, prognostic study.

Patient Expectations and Preferences in the Spinal Surgery Clinic

BACKGROUND

Managing patient expectations is essential in the treatment of patients undergoing spinal surgery. Patient satisfaction is associated with improved clinical outcomes and can be improved when patient and surgeon expectations are aligned and patient preferences are met.

METHODS

Patients presenting to clinic for management of spinal disease were asked to complete a questionnaire assessing demographics, current pain, reason for visit, and expectations and preferences surrounding the clinic experience. Variables were compared with χ² tests to determine factors associated with patient expectations. Subsets of new patients and returning patients were compared by the use of matched pair tests. One-way analysis of variance was used to compare means of clinic expectations in patients depending on their level of education.

RESULTS

A total of 240 patients were included. New patient evaluation was the most common reason for evaluation (26.6%), and pain relief was the most common chief concern (39.3%). Patients preferred their surgeon wash their hands in the room instead of before entering (P < 0.001) and wear professional attire over scrubs (P < 0.001). Patients believe their wait time will be longer than it should be (P = 0.002), they will spend longer in clinic than they should (P = 0.03), and they will get less face-to-face time with their surgeon than they should (P < 0.01) but also that the surgeon is not getting paid enough for the clinic visit (P = 0.02).

CONCLUSIONS

Because spine surgery is largely elective, patients often seek treatment to improve quality of life and alleviate subjective symptoms. Understanding patient expectations is critical to ensure that patients and physicians are working toward similar goals.

Hip Preservation Surgery Expectations Survey: A New Method to Measure Patients' Preoperative Expectations

PURPOSE

To develop a patient-derived expectations survey for hip preservation surgery.

METHODS

Patients were eligible if they were undergoing primary hip surgery and were recruited in person or by telephone. The survey was developed in 3 phases. During phase 1, 64 patients were interviewed preoperatively and asked open-ended questions about their expectations of surgery; a draft survey was assembled by categorizing responses. During phase 2, the survey was administered twice to another group of 50 patients preoperatively to assess test-retest reliability and concordance was measured with weighted kappa values and intraclass correlations. All patients also completed valid standard hip surveys electronically. During phase 3, final items were selected, factor analysis was performed, and a scoring system was developed.

RESULTS

In phase 1, 509 expectations were volunteered from which 21 distinct categories were discerned and became the items for the draft survey. In phase 2, the draft survey was completed twice, 4 days apart. In phase 3, all 21 items were retained for the final survey addressing pain, mobility, sports, resumption of active lifestyles, future function, and psychological well-being. An overall score is calculated from the number of items expected and the amount of improvement expected, and ranges from 0 to 100; higher is more expectations. For phase 2 patients, mean scores for both administrations were 82, Cronbach alpha coefficients were 0.88 and 0.91, and the intraclass correlation was 0.92. A higher score (i.e., greater expectations) was associated with worse hip condition measured by standard hip surveys (P ≤ .05).

CONCLUSIONS

We developed a patient-derived survey that is valid, reliable, and addresses a spectrum of expectations. The survey generates an overall score that is easy to calculate and interpret and offers a practical and comprehensive way to record patients' preoperative expectations.

LEVEL OF EVIDENCE

Level II, prognostic study, prospective sample.

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.

Measuring patient satisfaction in orthopaedic surgery

In addition to their wish to understand the clinical results of orthopaedic interventions, clinicians, patients, and payers are increasingly interested in patient satisfaction, both with the process of care and with outcomes. The construct of satisfaction is complex and depends on the context in which care takes place, including the nature of treatment, its setting, and most importantly the expectation of patients prior to treatment. The characteristics of scales that are effective measures of satisfaction are the same as those of all effective measurement instruments--i.e., reliability, validity, and responsiveness. Measurement of patient satisfaction may be especially important in evaluations of established procedures and processes so that the value of those procedures and processes to patients can be more completely understood.

Physical and psychological comorbidity independently associated with spine-related disability

STUDY DESIGN

Cross sectional analysis of patient-reported spine-related disability and comorbidity.

OBJECTIVE

To determine if nonorthopedic physical and psychological comorbidity are independently associated with self-reported spine-related disability in patients scheduled for spine surgery.

SUMMARY OF BACKGROUND DATA

The association between psychological comorbidity and spine-related disability is well known; less is known about the contribution of nonorthopedic physical comorbidity to patients' ratings of spine-related disability.

METHODS

Several days before surgery, 175 patients with cervical problems and 538 patients with lumbar problems completed the Neck Disability Index and the Oswestry Disability Index, respectively; scores range from 0% to 100%; higher scores reflect more disability. The Charlson Comorbidity Index, a standard index of weighted major physical comorbidity, was used to dichotomize patients according to no major physical comorbidity (Charlson Comorbidity Index=0) or any major physical comorbidity (Charlson Comorbidity Index≥1). Psychological comorbidity was measured for depressive symptoms and anxiety with validated scales.

RESULTS

Mean age of patients with cervical problems was 54 years, 60% were males, mean Neck Disability Index score was 44%, and 25% had major physical comorbidity. In multivariate analysis controlling for younger age (P<0.0001) and female sex (P<0.0001), more depressive symptoms (P=0.0003), and having major physical comorbidity (P=0.02) were associated with worse Neck Disability Index scores. Mean age of patients with lumbar problems was 56 years, 55% were males, mean Oswestry Disability Index score was 56%, and 30% had major physical comorbidity. In multivariate analysis controlling for younger age (P=0.36) and female sex (P=0.002), more depressive symptoms (P<0.0001), and having major physical comorbidity (P=0.03) were associated with worse Oswestry Disability Index scores.

CONCLUSION

Psychological comorbidity and nonorthopedic physical comorbidity measured by a standard index are associated with patient-reported spine-related disability in patients undergoing cervical and lumbar spine surgery. Given that disability is a major indicator for surgery, how psychological and physical comorbidity influence patients' assessment of spine-related disability merits further investigation.

LEVEL OF EVIDENCE

2.

Patients' expectations of cervical spine surgery

STUDY DESIGN

Cross-sectional analysis of patients' expectations of cervical spine surgery using the Hospital for Special Surgery Cervical Spine Surgery Expectations Survey (Expectations Survey).

OBJECTIVE

To preoperatively describe patients' long-term expectations of surgery in terms of demographic, clinical, and psychological characteristics.

SUMMARY OF BACKGROUND DATA

Although important components of patient-centered care, few studies have systematically considered patients' expectations of cervical spine surgery.

METHODS

Several days before surgery, 150 patients completed the Expectations Survey, which is composed of 20 physical and psychological items; scores range from 0 to 100, and higher scores reflect choosing more items and more improvement (i.e., more expectations). Patients completed additional questionnaires addressing demographic, psychological, and clinical status, including disability due to pain with the Neck Disability Index (NDI) and overall physical and mental health with the 12-item Short Form Health Survey.

RESULTS

Mean age was 54 years, and 61% were males. The most commonly chosen items were relieve neck (87%) and upper extremity (85%) pain, stop the spine condition from getting worse (97%), and remove the control the spine condition had on life (96%). Twenty-three percent of patients chose all 20 items, 39% chose 16 to 19 items, and 38% chose 15 or fewer items. In multivariate analysis, patients were more likely to choose more items if they were younger (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.0; P = 0.01), had worse NDI scores (OR = 6.5; 95% CI, 3.2-13.2; P < 0.0001), and had worse SF-12 Physical (OR = 1.9; 95% CI, 1.0-3.6; P = 0.05) and Mental Health scores (OR = 2.0; 95% CI, 1.1-3.6; P = 0.02). The Expectations Survey scores ranged from 10 to 100, and the mean score was 65 ± 24. In multivariate analysis, patients were more likely to have higher scores if they were younger (OR = 2.8; 95% CI, 1.4-6.0; P = 0.006) and had worse NDI scores (OR = 6.0; 95% CI, 2.8-13.2; P < 0.0001).

CONCLUSION

Multiple clinical variables were associated with expectations, with younger age and more disability due to pain being the most consistently associated with more expectations.

LEVEL OF EVIDENCE

3.