CORR Insights®: Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

Where Are We Now?

In the late 1970s, University of Notre Dame professor of medical anthropology Dr. Irwin Press partnered with a statistician colleague, Dr. Rod Ganey, to create Press-Ganey’s first validated survey to measure patient satisfaction [6]. Over the following decades, more hospitals began to collect Press-Ganey scores, and the federal government took notice [7]. In 2002, the Centers for Medicaid and Medicare Services helped to create a survey called the Hospital Consumer Assessment of Healthcare Providers and Systems for adult inpatients. The first public reporting of Hospital Consumer Assessment of Healthcare Providers and Systems data occurred in March 2008, and a new era of healthcare quality assessment began.

During this period, it was established that patient experience is related to clinical safety and effectiveness in almost all specialties [3]. Furthermore, physician-to-patient communication is strongly correlated with patient satisfaction. In a study of patients seen by hand surgeons after a single office visit, physician empathy alone was found to account for 65% of the variation in satisfaction scores [4]. In a study on patients who underwent hand surgery for Dupuytren's, there was only a weak association between objective improvement in finger function and satisfaction after treatment [5]. The authors emphasized the importance of assessing domains related to patient satisfaction other than clinical measures. Furthermore, the type of communication needed for a patient visiting the office might be different from that needed for patients seen perioperatively. In a study of more than 3000 orthopaedic clinic visits, underlying depression was an independent factor for decreased satisfaction [8].

Surgical subspecialties differ from other areas of medicine because physicians interact with patients in the office as well as in the operating room. In the present study by Blackburn et al. [1], patients who underwent surgical treatment for de Quervain’s tenosynovitis were prospectively followed in order to correlate preoperative psychosocial factors with pain and function after surgery. The authors found that after adjusting for demographic characteristics, psychosocial factors, and baseline scores, only patient expectations of treatment and how long their illness would last were associated with the total outcome score at 3 months.

Interestingly, the authors published a prior paper [2] evaluating similar factors in association with outcomes for patients who had not yet had surgery for de Quervain’s tenosynovitis. In that study, psychological variables such as pain catastrophizing, emotional distress, and negative perception were associated with a one-third to one-fifth lower Patient-Related Wrist/Hand Evaluation score. Based on the findings of Blackburn et al. [1], different factors influence patient satisfaction in a preoperative versus postoperative visit.

Where Do We Need To Go?

How can we use these findings to improve outcomes for patients who undergo surgery? Blackburn et al. [1] showed that preoperatively, patients are the most affected by the uncertainty they feel about their condition. The question regarding consequences, “how much does your illness affect your life?,” had a significant beta of 0.31. Pain catastrophizing, a scale that asks about rumination, magnification, and helplessness with regard to pain, had a beta of 0.17, and the response to the question “how much does your illness affect you emotionally?” had a beta of 0.14. During preoperative visits, patients are emotionally preoccupied with their illness, and these nonmodifiable, patient-specific feelings have a large impact on their overall satisfaction.

Using the same questionnaire, the authors found there were differences in results collected after surgery [1]. For patients in the postoperative group, there was an association between the outcome and their response to the question “how long do you think your illness will continue?,” as well as with their expectations of treatment. In contrast to the preoperative group, pain catastrophizing, consequences, and emotional representation did not reach statistical significance.

These two studies [1, 2] show important differences between a preoperative office visit and after hand surgery for de Quervain’s tenosynovitis regarding factors affecting patient-reported satisfaction. Preoperatively, patients are the most affected by their emotional response to the disease, while postoperatively, patients are focused on the details and timeline of treatment. Surgical residency training does not specifically train practitioners to manage complex psychosocial issues, which play a dominant role in satisfaction during office visits. However, surgeons may direct their postoperative discussions toward the patient's expectation of treatment and how long the illness will last before recovery occurs. The findings from this study [1] could be very important for orthopaedic surgeons if the findings are generalizable to other types of patients undergoing operative treatment.

How Do We Get There?

As the authors [1] have noted, future prospective studies could be designed to evaluate whether improving communication for those two domains would result in improved patient-reported outcomes. In the preoperative group, emotional feelings of distress regarding the disease process may vary among patients and might be impacted by the underlying level of depression in the group. The presence of severe comorbidities would likely confound the outcomes as well. Preoperatively, patients might benefit from psychological interventions to address these issues. It would also be beneficial for surgeons to have an easily administered instrument that could identify and/or treat underlying emotional pain. Finally, further studies are needed to show that these findings can be applied to patients undergoing other procedures than release for de Quervain’s tenosynovitis.

In postoperative studies, practitioners could be directed to communicate details of the treatment and evaluate whether any improvement occurs in outcome measures. Blackburn et al. [1] also suggested using a decision aid preoperatively to allow patients to feel more knowledgeable and in control of their postoperative course.

Studies such as the current one by Blackburn et al. [1] are valuable to all orthopaedic surgeons, but especially to those in training. Patient satisfaction is known to be correlated with safety and clinical efficacy [3]. In addition to critically analyzing technical measures of success, surgeons should take the time to help the patient understand how the treatment will occur and the length of time anticipated for recovery.