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

Abstract

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.

Fig. 1

Inclusion/exclusion tree.

Fig. 2

The Expectancy-discrepancy model. Expectations form a point of reference for the patient to evaluate the procedure. If the evaluation (perceived quality of care) is better than expected, there is positive a positive mismatch (positive disconfirmation), leading to satisfaction. If the evaluation is worse than expected, there is a negative mismatch (negative disconfirmation), leading to dissatisfaction.

Fig. 3

The Assimilation model. If the individual’s perceived quality of care is different from what they expected, they will adjust their evaluation to be closer to their expectation. The adjusted evaluation then leads to satisfaction or dissatisfaction with the procedure.

Fig. 4

A diagram of the assimilation-contrast model. When the evaluation of the procedure is far from the individual’s expectations, the patient will emphasize the mismatch between their expectations and their evaluation (disconfirmation). When the evaluation of the procedure is close to expectations, assimilation occurs, and the individual will adjust their evaluation to be in accordance with their expectations.