CORR Insights®: Treatment Invasiveness and Illness Perceptions Are Strongly Associated With Outcome Expectations in Patients Treated for Hand or Wrist Conditions: A Cross-sectional Study

Where Are We Now?

Patients’ expectations refer to future-directed beliefs that focus on whether a specific event or experience will occur [10]. These expectations play an important role in physical and mental health. In addition, they contribute to the placebo and nocebo effects, the latter being a negative result of treatment arising from the anticipation that an intervention will not work or will cause harm [4]. Ordinary expectations should not be confused with hopes or desires for a perfect result, which are sometimes called ideal expectations, values expectations, or fantasies [12].

Placebo-controlled surgical trials have been performed about arthroscopic meniscectomy, shoulder surgery, and spine surgery; to some surgeons’ dismay, they’ve shown the sham procedure to be little different from (and often as effective as) the “real” intervention [11]. The magnitude of the surgical placebo effect differs across studies, but improvements occur in about half of patients who receive a sham surgical intervention [6].

Good evidence suggests that expectations influence treatment outcomes and quality of life in patients treated for a wide variety of medical conditions and patients undergoing surgical procedures [1, 2]. Additionally, patients’ expectations are associated not only with treatment outcomes, but also with treatment satisfaction. In a prospective study, Hamilton et al. [8] found that one of the most-potent variables associated with satisfaction after lower extremity joint arthroplasty was whether the patient’s preoperative expectations were met. However, expectations depend on the type of treatment; one study found that among patients with carpometacarpal osteoarthritis, expectations were significantly higher in patients scheduled for surgery than in those scheduled for nonoperative treatment [9].

In this month’s Clinical Orthopaedics and Related Research®, de Ridder et al. [3] found that patients planning to have surgery had more-positive expectations about the treatment’s outcome than did patients who had nonsurgical treatment, even after accounting for differences in clinical and psychosocial profiles. They also found that patients with more-positive perceptions of their illnesses had more-positive expectations about their treatments. Thus, surgeons should provide preoperative intervention (education) to increase a patient’s understanding of the specific illness (hand and wrist conditions) and correct negative beliefs regarding treatment (invasiveness) in an effort to increase patients’ expectations.

Where Do We Need To Go?

Despite evidence showing the association of presurgical expectations with postsurgical outcomes, problems arise when this evidence is transferred to a clinical scenario. Problems include the lack of a standard or consistent measures of expectations and the remarkable heterogeneity of studies, along with substantially different methods and definitions of outcomes. Several reviews [1, 5, 16] concluded that we lack a standardized approach to assessing patients’ expectations. Additionally, many instruments that measure expectations were developed and used for only one study, and often, studies do not provide data on the psychometric properties of the tools they use. The lack of knowledge about the reliability and validity of these instruments questions those studies’ conclusions.

Because evidence shows that patient expectations have a strong association with posttreatment outcomes, an approach based on managing presurgical expectations might improve the results of the operations we perform. But there are important gaps in our knowledge. Although one study found that positive expectations were associated with shorter length of stay and fewer complications [7], others found that patient satisfaction after surgery was associated not with positive presurgical expectations but rather with the achievement of those expectations [8, 13]. The difference may be related to the types of surgery being performed. This difference suggests expectation management should be tailored to the specific treatment (nonsurgical or surgical, as well as the type of surgery) and to the specific characteristics of the patient being treated (our approach might vary with differing patients’ perceptions about illness or the presence and severity of the patient’s emotional distress, if any).

How Do We Get There?

Future researchers should determine whether medical caregivers should focus more on promoting positive expectations or on promoting realistic expectations. This implies that first, an attempt should be made to improve patients’ mental health. Second, the aim should be to establish realistic expectations for patients before surgery. There are ongoing randomized controlled trials that aim to analyze the effect of manipulated expectations on postsurgical recovery [14, 15]. The objective of these randomized clinical trials is to examine the effect of an intervention designed to improve expectations, and I believe the results of these will be informative. Future trials should evaluate the impact of such interventions, comparing expectation management between nonsurgical and surgical treatments as well as between specific interventions to improve illness perception and help patients understand their disease.

Finally, more work needs to be done to validate the commonly used instruments used to measure patients’ expectations in this context, and investigators should restrict their use of these tools to those that have been well validated.