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Correspondence

Patient Expectations and Total Joint Arthroplasty

To the Editor:

We read with interest the article on patient expectations and total joint arthroplasty outcomes by Mahomed, et al¹. However, we have major reservations about this work that we would like to raise.

We believe that the methodology used is inappropriate and that the concept of "expectations" of surgical outcomes is a flawed one. It has commonly been stated that expectations play a central and dominant role in influencing satisfaction (as Mahomed has shown)^2-4, although the nature of this relationship remains unclear. The majority of the quantitative studies that examine this relationship report that patients are able to describe their expectations of an outcome, via the use of questionnaires, rating scales, or open-ended questions^5,6. However, qualitative studies (using semistructured interviews) find the opposite: individuals actually find it difficult to identify or articulate their expectations^7,8. We conducted a qualitative study to further explore the relationship between expectations and satisfaction. Twenty-five patients were interviewed 3 months before primary total knee replacement (TKR) and 10 were followed up and interviewed again 6 months after their TKR. We found (like the previous qualitative studies) that most patients were unable or unwilling to express expectations and were generally evasive and noncommittal in their replies. They often began with a disclaimer such as "I don't know until the time comes," or "I'm not expecting anything." Instead, they framed their responses in terms of hopes and fears. The majority of the informants generally held 2 types of hopes: "ideal" hopes and "pragmatic" hopes, reflecting both the optimistic view of the outcome and the probability of achieving this. Expectations and hopes are very different concepts. Hopes tend to be based more upon emotions or wishes, things that individuals want reality to be, whereas expectations tend to rely more heavily upon rational thought and logical reasoning. Thus, the informants in this study were not able to "forecast" what they thought would happen, but were only able to theorize their hopes and fears.

An important finding from our research was that it was only at the postoperation interview that the informants were able to describe their expectations (what they really thought would happen) in the light of what actually occurred in the hospital and operation process. Thus, it was only in retrospect and evaluation after the event that the informants were able to formulate ideas of what they were really expecting. This has important implications for research that suggests satisfaction is influenced by expectations. The fact that many realities are unanticipated means that individuals may not know what to expect. Therefore, expectations cannot be used as a starting place on which to base an assessment of the level of satisfaction.

An important question remains: Why do quantitative studies demonstrate that patients have clear expectations about the outcomes of surgery, but qualitative studies tend to report them as tentative, vague, and even nonexistent? One reason may be due to the limitations of questionnaire design. Simple and direct questions about expectations may result in simplistic answers. In addition, the limited fixed choices provided in questionnaires or the few open-ended questions about their expectations may have led some patients to "pigeon-hole" responses or express a view that did not represent or capture the complexity of this concept. Qualitative studies, however, retain the complexity and contradictions in the analysis and therefore explore in more detail the context in which statements are made. Mahomed, et al used a self-report questionnaire to ascertain the expectations for pain relief, activities of daily living, overall success of surgery, and likelihood of complications, with a 4-point Likert scale of responses. A better construct may be to record the main hopes and fears of the patients, rather than forcing views into a narrow range of responses.

Further, the interviews carried out after surgery in our qualitative study indicated that individuals struggled to understand their outcome and often described their outcome in contradictory terms: they viewed the outcome of the TKR as positive despite the continued experience of pain and immobility. They presented both a "public" expression of the outcome, reflecting their socially desired view as a success, and a "private" expression of the TKR outcome, reflecting the remaining pain and disability. The public statement of the outcome from TKR may correspond to the favorable published results of TKR. However, the private expression of any remaining pain and restriction of movement may not be captured with quantitative methods. Examination of the case studies demonstrated that these apparently contradictory accounts were consistent in the context of the informants' lives, and represented adaptation, rationalization, or accommodation to their changed health state. As a result of these explanations, they continued to consider the TKR with high regard, even if they had considerable pain and disability.

We recommend that the concept of expectations needs reconceptualizing, and more sensitive assessments of outcome are needed to capture patients' experiences, which incorporate the process of reconceptualizing outcome and take into account the context of the individual.

GILLIAN WOOLHEAD, PhD; JENNY DONOVAN, PhD; PAUL DIEPPE, MD, Department of Social Medicine, the University of Bristol, MRC Health Services Research Collaboration, University of Bristol, Bristol, UK.

REFERENCES

1. Mahomed NN, Liang MH, Cook EF, et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol 2002;29:1273-9.

2. Lochman JE. Factors related to patients' satisfaction with their medical care. J Community Health 1983;9:91-109.

3. Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982;16:577-82.

4. Ross CK, Sinacore JM, Stiers W, Budiman-Mak E. The role of expectations and preferences in health care satisfaction of patients with arthritis. Arthritis Care Res 1990;3:92-8.

5. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients' expectations of knee surgery. J Bone Joint Surg Am 2001; 83:1005-12.

6. Jones KR, Burney RE, Christy B. Patient expectations for surgery: are they being met? J Qual Improvement 2000;26:349-60.

7. Haas M. The relationship between expectations and satisfaction: a qualitative study of patients' experiences of surgery for gynaecological cancer. Health Expectations 1999;2:51-60.

8. Fitzpatrick R, Hopkins A. Problems in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illness 1983;5:297-311.

Drs. Mohamed, et al reply

To the Editor:

We are pleased to have the opportunity to respond to the letter by Drs. Woolhead, Donovan, and Dieppe concerning our article¹. They raise interesting concerns about the methodology we used and the concept of expectations.

Our study was a prospective cohort design that evaluated the determinants of functional outcomes following primary total hip and knee arthroplasty in 2 centers. Subjects were evaluated using standardized outcome instruments that have been validated in the literature^2,3. As Dr. Woolhead acknowledges, the use of quantitative methods to measure expectations is commonly used. It is not surprising that qualitative methods often lead to different insights, as the responses are often influenced by the context of the interview. Both approaches provide valuable information and are useful in understanding the complex relationship between expectations and outcomes.

A growing body of literature examines the association of patient expectations on outcomes following medical or surgical interventions^4-8. In fact, Dr. Woolhead cites a number of these in her letter. We agree that the relationship between patient expectations and satisfaction is poorly understood, although it is likely that initial expectations shape the perceptions of later experiences, and that gaps between expected and achieved outcomes strongly influence satisfaction⁹. In part, this may reflect lack of conceptual clarity about what expectations truly mean and lack of uniformity in how expectations are measured. It seems Dr. Woolhead and colleagues are addressing these very issues in their current research; we look forward to learning from their findings. In our study, however, we looked at the relationship between expectations and functional outcomes following surgery. Functional outcomes as defined in our study measure self-reported pain and disability rather than satisfaction with the result of the surgery. The field of measurement technology is quite mature in the area of functional outcomes. Indeed the Western Ontario McMaster Osteoarthritis Index (WOMAC, the primary dependent outcome in our study) has been validated and used extensively^2,3,10-12. When Woolhead, et al refer to functional outcomes and satisfaction as interchangeable constructs, this in our opinion is incorrect.

Finally, we disagree with the suggestion that expectations regarding a procedure should be measured after the intervention. Recalled expectations are subject to strong recall bias and can be confounded by outcomes of the surgery. Patients' recall of their expectations may be dramatically altered from prior to surgery if they had a complication or adverse event after surgery. Conversely, if they achieve an excellent result they may raise their recalled level of expectations. The only way to accurately assess patient expectations of surgery is to measure them before the intervention. This is the strength of our study, as most previous reports have relied on recall expectations^4,5. Ideally, researchers could combine quantitative assessments of expectation with qualitative assessments of hopes and fear in prospective research to illuminate their contributions to both outcomes and satisfaction.

NIZAR N. MAHOMED, MD, ScD, Toronto Western Hospital, Toronto, Canada; MATTHEW H. LIANG, MD, MPH; LAWREN H. DALTROY, PhD; PAUL R. FORTIN, MD, MPH; JEFFREY N. KATZ, MD, MSc, Brigham and Women's Hospital, Boston, Massachusetts, USA.

REFERENCES

1. Mahomed NN, Liang MH, Cook EF, et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol 2002;29:1273-9.

2. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. 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;15:1833-40.

3. Bellamy N. Pain assessment in osteoarthritis: experience with the WOMAC Osteoarthritis Index. Semin Arthritis Rheum 1989; 18:14-7.

4. Burton KE, Wright V, Richards J. Patients' expectations in relation to outcome of total hip replacement surgery. Ann Rheum Dis 1979;38:471-4.

5. Mancuso CA, Salvati EA, Johanson NA, Peterson MGE, Charlson ME. Patients' expectations and satisfaction with total hip arthroplasty. J Arthroplasty 1997;12:387-96.

6. Ross CK, Sinacore JM, Stiers W, Budiman-Mak E. The role of expectations and preferences in health care satisfaction of patients with arthritis. Arthritis Care Res 1990;3:92-8.

7. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients' expectations of knee surgery. J Bone Joint Surg Am 2001; 83:1005-12.

8. Leedham B, Meyerowitz BE, Muirhead J, Frist WH. Positive expectations predict health after heart transplantation. Health Psychol 1995;14:74-9.

9. Ross CK, Frommelt G, Hazelwood L, Chang RW. The role of expectations in patient satisfaction with medical care. J Health Care Management 1987;7:16-26.

10. Bellamy N, Kean WF, Buchanan WW, Gerecz-Simon E, Campbell J. Double blind randomized controlled trial of sodium meclofenamate (Meclomen) and diclofenac sodium (Voltaren): post validation reapplication of the WOMAC Osteoarthritis Index. J Rheumatol 1992;19:153-9.

11. Bombardier C, Melfi CA, Paul J, et al. Comparison of a generic and a disease-specific measure of pain and physical function after knee replacement surgery. Med Care 1995;33:AS131-44.

12. Hawker G, Melfi C, Paul J, Green R, Bombardier C. Comparison of a generic (SF-36) and a disease specific (WOMAC) (Western Ontario and McMaster Universities Osteoarthritis Index) instrument in the measurement of outcomes after knee replacement surgery. J Rheumatol 1995;22:1193-6.