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

Published:December 18, 2013DOI:https://doi.org/10.1016/j.surg.2013.12.015

      Background

      Recent events in health care reform have brought national attention to integrating patient experiences and expectations into quality metrics. Few studies have comprehensively evaluated the effect of patient expectations on patient-reported outcomes (PROs) after surgery. The purpose of this study is to systematically review the available literature describing the relationship between patient expectations and postoperative PROs.

      Methods

      We performed a search of the literature published before November 1, 2012. Articles were included in the review if (1) primary data were presented, (2) patient expectations regarding a surgical procedure were measured, (3) PROs were measured, and (4) the relationship between patient expectations and PROs was specifically examined. PROs were categorized into 5 subgroups: Satisfaction, quality of life (QOL), disability, mood disorder, and pain. We examined each study to determine the relationship between patient expectations and PROs as well as study quality.

      Results

      From the initial literature search yielding 1,708 studies, 60 articles were included. Fulfillment of expectations was associated with improved PROs among 24 studies. Positive expectations were correlated with improved PROs for 28 studies (47%), and poorer PROs for 9 studies (15%). Eighteen studies reported that fulfillment of expectations was correlated with improved patient satisfaction, and 10 studies identified that positive expectations were correlated with improved postoperative. Finally, patients with positive preoperative expectations reported less pain (8 studies) and disability (15 studies) compared with patients with negative preoperative expectations.

      Conclusion

      Patient expectations are inconsistently correlated with PROs after surgery, and there is no accepted method to capture perioperative expectations. Future efforts to rigorously measure expectations and explore their influence on postoperative outcomes can inform clinicians and policymakers seeking to integrate PROs into measures of surgical quality.
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      References

        • US Institute of Medicine
        Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century.
        National Academy Press, Washington, DC2001
        • Prioritization IoMCoCER
        Initial National Priorities for Comparative Effectiveness Research.
        The National Academies Press, Washington, DC2009
        • Birkmeyer J.D.
        • Gust C.
        • Baser O.
        • Dimick J.B.
        • Sutherland J.M.
        • Skinner J.S.
        Medicare payments for common inpatient procedures: implications for episode-based payment bundling.
        Health Serv Res. 2010; 45: 1783-1795
        • Kohn L.T.
        • Corrigan J.
        • Donaldson M.S.
        • US Institute of Medicine
        Committee on Quality of Health Care in America. To err is human building a safer health system.
        National Academy Press, Washington, DC1999 (Available from:)
        • Birkmeyer J.D.
        • Siewers A.E.
        • Finlayson E.V.
        • et al.
        Hospital volume and surgical mortality in the United States.
        N Engl J Med. 2002; 346: 1128-1137
        • Birkmeyer J.D.
        • Stukel T.A.
        • Siewers A.E.
        • Goodney P.P.
        • Wennberg D.E.
        • Lucas F.L.
        Surgeon volume and operative mortality in the United States.
        N Engl J Med. 2003; 349: 2117-2127
        • Birkmeyer J.D.
        • Dimick J.B.
        • Birkmeyer N.J.
        Measuring the quality of surgical care: structure, process, or outcomes?.
        J Am Coll Surg. 2004; 198: 626-632
        • Brook R.H.
        Can the Patient-Centered Outcomes Research Institute become relevant to controlling medical costs and improving value?.
        JAMA. 2011; 306: 2020-2021
        • Laine C.
        • Davidoff F.
        Patient-centered medicine. A professional evolution.
        JAMA. 1996; 275: 152-156
        • Rao J.K.
        • Weinberger M.
        • Kroenke K.
        Visit-specific expectations and patient-centered outcomes: a literature review.
        Arch Fam Med. 2000; 9: 1148-1155
        • Waljee J.F.
        • Ubel P.A.
        • Atisha D.M.
        • Hu E.S.
        • Alderman A.K.
        The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma?.
        Ann Surg Oncol. 2011; 18: 2477-2482
        • Ubel P.A.
        • Loewenstein G.
        • Jepson C.
        Disability and sunshine: can hedonic predictions be improved by drawing attention to focusing illusions or emotional adaptation?.
        J Exp Psychol Appl. 2005; 11: 111-123
        • Damschroder L.J.
        • Zikmund-Fisher B.J.
        • Ubel P.A.
        The impact of considering adaptation in health state valuation.
        Soc Sci Med. 2005; 61: 267-277
        • Smith D.
        • Loewenstein G.
        • Jepson C.
        • Jankovich A.
        • Feldman H.
        • Ubel P.
        Mispredicting and misremembering: patients with renal failure overestimate improvements in quality of life after a kidney transplant.
        Health Psychol. 2008; 27: 653-658
        • Smith D.M.
        • Sherriff R.L.
        • Damschroder L.
        • Loewenstein G.
        • Ubel P.A.
        Misremembering colostomies? Former patients give lower utility ratings than do current patients.
        Health Psychol. 2006; 25: 688-695
        • Smith D.M.
        • Loewenstein G.
        • Rozin P.
        • Sherriff R.L.
        • Ubel P.A.
        Sensitivity to disgust, stigma, and adjustment to life with a colostomy.
        J Res Pers. 2007; 41: 787-803
        • Ram A.N.
        • Curtin C.M.
        • Chung K.C.
        Population-based utilities for upper extremity functions in the setting of tetraplegia.
        J Hand Surg Am. 2009; 34: 1674-1681.e1671
        • Wilson K.A.
        • Dowling A.J.
        • Abdolell M.
        • Tannock I.F.
        Perception of quality of life by patients, partners and treating physicians.
        Qual Life Res. 2000; 9: 1041-1052
        • Brown L.K.
        • Waljee A.K.
        • Higgins P.D.
        • Waljee J.F.
        • Morris A.M.
        Proximity to disease and perception of utility: physicians' vs patients' assessment of treatment options for ulcerative colitis.
        Dis Colon Rectum. 2011; 54: 1529-1536
        • Boyd N.F.
        • Sutherland H.J.
        • Heasman K.Z.
        • Tritchler D.L.
        • Cummings B.J.
        Whose utilities for decision analysis?.
        Med Decis Making. 1990; 10: 58-67
        • Rozenblum R.
        • Lisby M.
        • Hockey P.M.
        • et al.
        Uncovering the blind spot of patient satisfaction: an international survey.
        BMJ Qual Saf. 2011; 20: 959-965
        • Harris R.P.
        • Helfand M.
        • Woolf S.H.
        • et al.
        Current methods of the US Preventive Services Task Force: a review of the process.
        Am J Prev Med. 2001; 20: 21-35
        • Soroceanu A.
        • Ching A.
        • Abdu W.
        • McGuire K.
        Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study.
        Spine. 2012; 37: E103-E108
        • Mancuso C.A.
        • Sculco T.P.
        • Wickiewicz T.L.
        • et al.
        Patients' expectations of knee surgery.
        J Bone Joint Surg Am. 2001; 83-A: 1005-1012
        • Addisu Z.
        • Solomon B.
        Patients' preoperative expectation and outcome of cataract surgery at jimma university specialized hospital -department of ophthalmology.
        Ethiop J Health Sci. 2011; 21: 47-55
        • Becker R.
        • Doring C.
        • Denecke A.
        • Brosz M.
        Expectation, satisfaction and clinical outcome of patients after total knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1433-1441
        • Brandberg Y.
        • Arver B.
        • Johansson H.
        • Wickman M.
        • Sandelin K.
        • Liljegren A.
        Less correspondence between expectations before and cosmetic results after risk-reducing mastectomy in women who are mutation carriers: a prospective study.
        Eur J Surg Oncol. 2012; 38: 38-43
        • Burton K.E.
        • Wright V.
        • Richards J.
        Patients' expectations in relation to outcome of total hip replacement surgery.
        Ann Rheum Dis. 1979; 38: 471-474
        • de Groot K.I.
        • Boeke S.
        • Passchier J.
        Preoperative expectations of pain and recovery in relation to postoperative disappointment in patients undergoing lumbar surgery.
        Med Care. 1999; 37: 149-156
        • Eisler T.
        • Svensson O.
        • Tengstrom A.
        • Elmstedt E.
        Patient expectation and satisfaction in revision total hip arthroplasty.
        J Arthroplasty. 2002; 17: 457-462
        • Finlay P.M.
        • Atkinson J.M.
        • Moos K.F.
        Orthognathic surgery: patient expectations; psychological profile and satisfaction with outcome.
        Br J Oral Maxillofac Surg. 1995; 33: 9-14
        • Gandhi R.
        • Davey J.R.
        • Mahomed N.
        Patient expectations predict greater pain relief with joint arthroplasty.
        J Arthroplasty. 2009; 24: 716-721
        • Gepstein R.
        • Arinzon Z.
        • Adunsky A.
        • Folman Y.
        Decompression surgery for lumbar spinal stenosis in the elderly: preoperative expectations and postoperative satisfaction.
        Spinal Cord. 2006; 44: 427-431
        • Haworth R.J.
        • Hopkins J.
        • Ells P.
        • Ackroyd C.E.
        • Mowat A.G.
        Expectations and outcome of total hip replacement.
        Rheumatol Rehabil. 1981; 20: 65-70
        • Iversen M.D.
        • Daltroy L.H.
        • Fossel A.H.
        • Katz J.N.
        The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis.
        Patient Educ Counsel. 1998; 34: 169-178
        • Kadzielski J.
        • Malhotra L.R.
        • Zurakowski D.
        • Lee S.-G.P.
        • Jupiter J.B.
        • Ring D.
        Evaluation of preoperative expectations and patient satisfaction after carpal tunnel release.
        J Hand Surg. 2008; 33: 1783-1788
        • Kiyak H.A.
        • Vitaliano P.P.
        • Crinean J.
        Patients' expectations as predictors of orthognathic surgery outcomes.
        Health Psychol. 1988; 7: 251-268
        • Kramer A.C.
        • Schweber A.
        Patient expectations prior to coloplast titan penile prosthesis implant predicts postoperative satisfaction.
        J Sex Med. 2010; 7: 2261-2266
        • Lindsay G.M.
        • Smith L.N.
        • Hanlon P.
        • Wheatley D.J.
        Coronary artery disease patients' perception of their health and expectations of benefit following coronary artery bypass grafting.
        J Adv Nurs. 2000; 32: 1412-1421
        • Lingard E.A.
        • Sledge C.B.
        • Learmonth I.D.
        • Kinemax Outcomes G.
        Patient expectations regarding total knee arthroplasty: differences among the United States, United kingdom, and Australia.
        J Bone Joint Surg Am. 2006; 88: 1201-1207
        • Lutz G.K.
        • Butzlaff M.E.
        • Atlas S.J.
        • Keller R.B.
        • Singer D.E.
        • Deyo R.A.
        The relation between expectations and outcomes in surgery for sciatica.
        J Gen Intern Med. 1999; 14: 740-744
        • Mancuso C.A.
        • Salvati E.A.
        • Johanson N.A.
        • Peterson M.G.
        • Charlson M.E.
        Patients' expectations and satisfaction with total hip arthroplasty.
        J Arthroplasty. 1997; 12: 387-396
        • Mannion A.F.
        • Kampfen S.
        • Munzinger U.
        • Kramers-de Quervain I.
        The role of patient expectations in predicting outcome after total knee arthroplasty.
        Arthritis Res Ther. 2009; 11: R139
        • McGregor A.H.
        • Hughes S.P.F.
        The evaluation of the surgical management of nerve root compression in patients with low back pain: part 2: patient expectations and satisfaction.
        Spine. 2002; 27: 1471-1476
        • Nilsdotter A.K.
        • Toksvig-Larsen S.
        • Roos E.M.
        Knee arthroplasty: are patients' expectations fulfilled? A prospective study of pain and function in 102 patients with 5-year follow-up.
        Acta Orthopaedica. 2009; 80: 55-61
        • Noble P.C.
        • Conditt M.A.
        • Cook K.F.
        • Mathis K.B.
        The John Insall Award: patient expectations affect satisfaction with total knee arthroplasty.
        Clin Orthop Rel Res. 2006; 452: 35-43
        • Olson R.E.
        • Laskin D.M.
        Expectations of patients from orthognathic surgery.
        J Oral Surg. 1980; 38: 283-285
        • Ostler S.
        • Kiyak H.A.
        Treatment expectations versus outcomes among orthognathic surgery patients.
        Int J Adult Orthodon Orthognath Surg. 1991; 6: 247-255
        • Pager C.K.
        Expectations and outcomes in cataract surgery: a prospective test of 2 models of satisfaction.
        Arch Ophthalmol. 2004; 122: 1788-1792
        • Ronnberg K.
        • Lind B.
        • Zoega B.
        • Halldin K.
        • Gellerstedt M.
        • Brisby H.
        Patients' satisfaction with provided care/information and expectations on clinical outcome after lumbar disc herniation surgery.
        Spine. 2007; 32: 256-261
        • Singh A.
        • Kendal A.
        • Trivedi D.
        • Cazabon S.
        Patient expectation and satisfaction after macular hole surgery.
        Optom Vis Sci. 2011; 88: 312-316
        • Snell L.
        • McCarthy C.
        • Klassen A.
        • et al.
        Clarifying the expectations of patients undergoing implant breast reconstruction: a qualitative study.
        Plast Reconstr Surg. 2010; 126: 1825-1830
        • Toyone T.
        • Tanaka T.
        • Kato D.
        • Kaneyama R.
        • Otsuka M.
        Patients' expectations and satisfaction in lumbar spine surgery.
        Spine. 2005; 30: 2689-2694
        • Velanovich V.
        • Kamolz T.
        • Pointner R.
        • Contini S.
        Qualitative analysis of the expectations of antireflux surgical outcomes of patients from different nationalities.
        Dis Esophagus. 2006; 19: 88-93
        • Wheelock I.
        • Peterson C.
        • Buchtel H.A.
        Presurgery expectations, postsurgery satisfaction, and psychosocial adjustment after epilepsy surgery.
        Epilepsia. 1998; 39: 487-494
        • Wilson S.J.
        • Saling M.M.
        • Kincade P.
        • Bladin P.F.
        Patient expectations of temporal lobe surgery.
        Epilepsia. 1998; 39: 167-174
        • Wilson S.J.
        • Saling M.M.
        • Lawrence J.
        • Bladin P.F.
        Outcome of temporal lobectomy: expectations and the prediction of perceived success.
        Epilepsy Res. 1999; 36: 1-14
        • Yee A.
        • Adjei N.
        • Do J.
        • Ford M.
        • Finkelstein J.
        Do patient expectations of spinal surgery relate to functional outcome?.
        Clin Orthop Rel Res. 2008; 466: 1154-1161
        • Zijlstra H.
        • Larsen J.K.
        • de Ridder D.T.D.
        • van Ramshorst B.
        • Geenen R.
        Initiation and maintenance of weight loss after laparoscopic adjustable gastric banding. The role of outcome expectation and satisfaction with the psychosocial outcome.
        Obes Surg. 2009; 19: 725-731
        • Mancuso C.A.
        • Jout J.
        • Salvati E.A.
        • Sculco T.P.
        Fulfillment of patients' expectations for total hip arthroplasty.
        J Bone Joint Surg Am. 2009; 91: 2073-2078
        • Chunta K.S.
        Expectations, anxiety, depression, and physical health status as predictors of recovery in open-heart surgery patients.
        J Cardiovasc Nurs. 2009; 24: 454-464
        • Cross M.
        • Lapsley H.
        • Barcenilla A.
        • Parker D.
        • Coolican M.
        • March L.
        Patient expectations of hip and knee joint replacement surgery and postoperative health status.
        Patient. 2009; 2: 51-60
        • Davidge K.
        • Bell R.
        • Ferguson P.
        • Turcotte R.
        • Wunder J.
        • Davis A.M.
        Patient expectations for surgical outcome in extremity soft tissue sarcoma.
        J Surg Oncol. 2009; 100: 375-381
        • Flood A.B.
        • Lorence D.P.
        • Ding J.
        • McPherson K.
        • Black N.A.
        The role of expectations in patients' reports of post-operative outcomes and improvement following therapy.
        Med Care. 1993; 31: 1043-1056
        • Gonzalez Saenz de Tejada M.
        • Escobar A.
        • Herrera C.
        • Garcia L.
        • Aizpuru F.
        • Sarasqueta C.
        Patient expectations and health-related quality of life outcomes following total joint replacement.
        Value Health. 2010; 13: 447-454
        • Haddad F.S.
        • Garbuz D.S.
        • Chambers G.K.
        • Jagpal T.J.
        • Masri B.A.
        • Duncan C.P.
        The expectations of patients undergoing revision hip arthroplasty.
        J Arthroplasty. 2001; 16: 87-91
        • Henn 3rd, R.F.
        • Kang L.
        • Tashjian R.Z.
        • Green A.
        Patients' preoperative expectations predict the outcome of rotator cuff repair.
        J Bone Joint Surg Am. 2007; 89: 1913-1919
        • Holzner B.
        • Kemmler G.
        • Kopp M.
        • et al.
        Preoperative expectations and postoperative quality of life in liver transplant survivors.
        Arch Phys Med Rehabil. 2001; 82: 73-79
        • Lee S.J.
        • Loberiza F.R.
        • Rizzo J.D.
        • Soiffer R.J.
        • Antin J.H.
        • Weeks J.C.
        Optimistic expectations and survival after hematopoietic stem cell transplantation.
        Biol Blood Marrow Transplant. 2003; 9: 389-396
        • Leedham B.
        • Meyerowitz B.E.
        • Muirhead J.
        • Frist W.H.
        Positive expectations predict health after heart transplantation.
        Health Psychol. 1995; 14: 74-79
        • Mahomed N.N.
        • Liang M.H.
        • Cook E.F.
        • et al.
        The importance of patient expectations in predicting functional outcomes after total joint arthroplasty.
        J Rheumatol. 2002; 29: 1273-1279
        • Oh J.H.
        • Yoon J.P.
        • Kim J.Y.
        • Kim S.H.
        Effect of expectations and concerns in rotator cuff disorders and correlations with preoperative patient characteristics.
        J Shoulder Elbow Surg. 2012; 21: 715-721
        • Saban K.L.
        • Penckofer S.M.
        Patient expectations of quality of life following lumbar spinal surgery.
        J Neurosci Nurs. 2007; 39: 180-189
        • Sears S.F.
        • Serber E.R.
        • Lewis T.S.
        • et al.
        Do positive health expectations and optimism relate to quality-of-life outcomes for the patient with an implantable cardioverter defibrillator?.
        J Cardiopulm Rehabil. 2004; 24: 324-331
        • Barefoot J.C.
        • Brummett B.H.
        • Williams R.B.
        • et al.
        Recovery expectations and long-term prognosis of patients with coronary heart disease.
        Arch Intern Med. 2011; 171: 929-935
        • Borkan J.M.
        • Quirk M.
        Expectations and outcomes after hip fracture among the elderly.
        Int J Aging Human Dev. 1992; 34: 339-350
        • Judge A.
        • Cooper C.
        • Arden N.K.
        • et al.
        Pre-operative expectation predicts 12-month post-operative outcome among patients undergoing primary total hip replacement in European orthopaedic centres.
        Osteoarthritis Cartilage. 2011; 19: 659-667
        • Mannion A.F.
        • Junge A.
        • Elfering A.
        • Dvorak J.
        • Porchet F.
        • Grob D.
        Great expectations: really the novel predictor of outcome after spinal surgery?.
        Spine. 2009; 34: 1590-1599
        • Paddison J.S.
        • Booth R.J.
        • Cameron L.D.
        • Robinson E.
        • Frizelle F.A.
        • Hill A.G.
        Fatigue after colorectal surgery and its relationship to patient expectations.
        J Surg Res. 2009; 151: 145-152
        • Suda A.J.
        • Seeger J.B.
        • Bitsch R.G.
        • Krueger M.
        • Clarius M.
        Are patients' expectations of hip and knee arthroplasty fulfilled? A prospective study of 130 patients.
        Orthopedics. 2010; 33: 76-80
        • Bellamy N.
        • Buchanan W.W.
        • Goldsmith C.H.
        • Campbell J.
        • Stitt L.W.
        Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
        J Rheumatol. 1988; 15: 1833-1840
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
        Am J Ind Med. 1996; 29: 602-608
        • Fairbank J.C.
        • Pynsent P.B.
        The Oswestry Disability Index.
        Spine. 2000; 25: 2940-2952
        • Wallace L.M.
        Surgical patients' expectations of pain and discomfort: does accuracy of expectations minimise post-surgical pain and distress?.
        Pain. 1985; 22: 363-373
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Scheier M.F.
        • Carver C.S.
        Optimism, coping, and health: assessment and implications of generalized outcome expectancies.
        Health Psychol. 1985; 4: 219-247
        • Bieling P.J.
        • Antony M.M.
        • Swinson R.P.
        The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.
        Behav Res Ther. 1998; 36: 777-788
        • Gavaruzzi T.
        • Carnaghi A.
        • Lotto L.
        • et al.
        Recalling pain experienced during a colonoscopy: pain expectation and variability.
        British Journal of Health Psychol. 2010; 15: 253-264
        • Oliver R.L.
        A cognitive model of the antecedents and consequences of satisfaction decisions.
        J Marketing Res. 1980; 17: 460-469
        • Anderson R.E.
        Consumer dissatisfaction - effect of disconfirmed expectancy on perceived product performance.
        J Marketing Res. 1973; 10: 38-44
        • Thompson A.G.
        • Sunol R.
        Expectations as determinants of patient satisfaction: concepts, theory and evidence.
        Int J Qual Health Care. 1995; 7: 127-141
        • Katz S.J.
        • Lantz P.M.
        • Janz N.K.
        • et al.
        Patient involvement in surgery treatment decisions for breast cancer.
        J Clin Oncol. 2005; 23: 5526-5533
        • Hawley S.T.
        • Lantz P.M.
        • Janz N.K.
        • et al.
        Factors associated with patient involvement in surgical treatment decision making for breast cancer.
        Patient Educ Couns. 2007; 65: 387-395
        • O'Connor A.M.
        • Llewellyn-Thomas H.A.
        • Flood A.B.
        Modifying unwarranted variations in health care: shared decision making using patient decision aids.
        Health Aff (Millwood). 2004; : VAR63-VAR72
        • Fagerlin A.
        • Lakhani I.
        • Lantz P.M.
        • et al.
        An informed decision? Breast cancer patients and their knowledge about treatment.
        Patient Educ Couns. 2006; 64: 303-312
        • Lee C.N.
        • Chang Y.
        • Adimorah N.
        • et al.
        Decision making about surgery for early-stage breast cancer.
        J Am Coll Surg. 2012; 214: 1-10
        • O'Connor A.M.
        • Stacey D.
        • Rovner D.
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2001; : CD001431
        • Fries J.
        • Bruce B.
        • Cella D.
        The promise of PROMIS: using item response theory to improve assessment of patient-reported outcomes.
        Clin Exp Rheumatol. 2005; 23: 53
        • Cella D.
        • Yount S.
        • Rothrock N.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years.
        Med Care. 2007; 45: S3-S11
        • Sepucha K.R.
        • Fowler Jr., F.J.
        • Mulley Jr., A.G.
        Policy support for patient-centered care: the need for measurable improvements in decision quality.
        Health Aff (Millwood). 2004; : VAR54-VAR62