Patient Expectations and Patient-Reported Outcomes in Surgery: A Systematic Review

In the United States, surgical procedures account for 40% of our total healthcare expenditures, and identifying effective measures of surgical quality is a top priority1-4. Although traditional quality indicators, such as hospital readmissions rates or length of stay, can be easily captured by administrative data, these outcomes may not be appropriate for all types of procedures. For example, for high-risk procedures, such as lung resection or pancreatectomy, mortality rates and procedural volume can distinguish surgeon and hospital performance 5,6. However, for common, low-risk procedures, these endpoints are exceedingly rare and not sensitive enough to distinguish variation in patient outcomes 7. Instead, patient-reported outcomes (PROs), such as health-related quality of life and disability, can illuminate differences in treatment effectiveness. In 2010, the Patient Centered Outcomes Research Institute was funded by the Affordable Care Act, and established PROs as a central component of healthcare policy and reform 8-10. Therefore, understanding the factors that influence PROs following surgery can inform strategies to improve the quality of surgical care. Patients enter each decision for surgery with expectations regarding the effectiveness of the procedure and their postoperative recovery. Their ability to accurately predict these outcomes is the foundation of an informed decision. However, most patients have inaccurate perceptions of both disease conditions and surgery. For example, women incorrectly estimate the quality of life and stigma associated with surgery for breast cancer 11. Similarly, patients with kidney disease often overestimate quality of life following renal transplantation, and the general public predicts poorer quality of life associated with spinal cord injury or colostomy creation than patients report 12-17. Physicians also have difficulty predicting patient recovery and adaptation following surgery 18. For example, physicians often underestimate quality of life following colorectal surgery, such as colostomy creation or total colectomy 19,20. These misconceptions can undermine the process of informed consent, erode patient trust in their physicians, and exacerbate medico-legal tensions. Therefore, understanding the effect of patient expectations on postoperative experiences and outcomes can identify communication barriers between patients and surgeons and improve the decision-making process for patients facing surgery. To date, the influence of preoperative expectations on PROs following surgery has not been systematically reviewed, and few physicians routinely address patient expectations prior to surgery 21. Therefore, the purpose of this study is to examine the literature describing the relationship between patient expectations and 5 specific PROs following surgery: satisfaction, quality of life, disability, mood disorders, and pain. We hypothesize that patients whose preoperative expectations are sufficiently met following surgery will experience improved outcomes compared with patients whose experience falls short of their expectations.