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The Expectation Game: Patient Comprehension Is a Determinant of Outcome
Editorial
The Expectation Game: Patient Comprehension Is a Determinant of Outcome
Abstract: Patient comprehension of orthopaedic procedures is low and their expectations for successful outcomes are often unrealistic. Surgeons need to understand this and guide patients toward sensible expectations.
USA Today has come out with a new surveydapparently, three out of every four people make up 75% of the population.1 David Letterman
S
urveys frequently tell us what is blatantly obvious. Rarely, they surprise us. On certain occasions, however, their conclusionsddespite being expectedddrive home a point to which we must listen. The value of survey studies can be called into question because of their inherent lower level of evidence; generally, as readers may have noticed, we do not list a level of evidence in reports of surveys of patients for this very reason, and surveys of surgeons are listed as Level V evidence, the lowest level. There are times, however, when the results of a survey should be highlighted. In this month’s issue, Brophy, Gefen, Matava, Wright, and Smith from Washington University in St. Louis report on their study of patients presenting to orthopaedic clinics, regardless of complaint, with regard to their understanding of arthroscopic meniscus surgery.2 The results: a typical patient has no better chance than a flip of a coin to correctly answer factual questions about meniscus surgery. In addition, patients have a complete misunderstanding of the incidence of meniscus repair versus meniscectomy; patients believe that repair is the most common treatment. We commend the authors for appropriately developing a survey questionnaire with a sixth-grade reading level, which reminds us of the often marked disparity between provider and patient. Recall that in addition to misconception, patients face challenges of comprehension with verbal communication of informed consent (when compared with video, which is still not perfect3). On a positive note, this past research showed that we Ó 2015 by the Arthroscopy Association of North America 0749-8063/15908/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.09.005
can improve patient comprehension, but it requires an effort, such as preparation of audiovisual aids. One might ask, “Why is this important?” or better yet, “Why does this matter so long as patients improve?” This is important because a patient’s improvement is an expectation game. In today’s age of outcome-driven performance and increased reliance on value-based medicine,4-8 understanding patients’ comprehension is of utmost importance. We are reminded that value is the simple quotient of outcome divided by cost.9 While costs can be estimated, the determination of outcome proves challenging; as J.J.P. Warner expressed critically in 2014 at the AANA Annual Meeting, “We don’t measure our outcomes and we have a poor consensus on outcomes measures.”10 In addition, outcome goals for one condition of one patient may be vastly different from another patient with the same condition. Patientreported outcome is personal, and individual patient expectations have a significant effect on the outcome of arthroscopy, including rotator cuff surgery, joint arthroplasty, and lumbar spine surgery.11-15 Thus, addressing patient expectations can be an important start. Notably, AANA and other orthopaedic societies now diligently strive to refine and implement prospective outcome measurement.16-20 Patients’ understanding, and thus their expectations, not only reflect accordingly on outcome measures, but have a direct impact on satisfaction surveys like the Press Ganey Survey. These surveys rank our performance, and they can and will be used for incentivebased pay. This is already being implemented despite evidence that a “patient’s underlying clinical condition may influence response to patient satisfaction surveys,” and the lack of any proof that this correlates with physician competence.21 In orthopaedic surgery, particularly arthroscopic surgery, we have the unique yet onerous task of treating pain and function. Patients often expect zero rather than
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 12 (December), 2015: pp 2283-2284
2283
2284
EDITORIAL
less pain and normal rather than improved function. We need to shift our patients away from these impractical beliefs to a more realistic understanding; a joint can be made better but not necessarily normal. As we have said before, this task also entails educating our primarycare colleagues, our legislature, and the press.22 But first, let us educate ourselves about our patients and what they know. Then we need to temper our own expectations of our patients’ outcome, because we can often be our own worst enemy; we should not assign personal blame for less than perfect results when perfect results do not exist. This issue also highlights another survey that deserves attention; Kibler and Sciascia23 supplement their systematic review of current practice for diagnosis of SLAP lesions with a survey of surgeon expert opinion (Level V evidence). Level V evidence has great value when systematic review of the literature fails to resolve a controversy, and where the literature is of poor methodological quality. The level of evidence assigned to Kibler and Sciascia’s article is according to the systematic review (Level IV evidence), as the Level V adjunctive survey requires no level of evidence, and seems more of a bonus than the primary research method. We point out this technicality just in case our argument above skewed reader expectations. Michael J. Rossi, M.D. Deputy Editor Jefferson C. Brand, M.D. Deputy Editor Matthew T. Provencher, M.D. Assistant Editor-in-Chief James H. Lubowitz, M.D. Editor-in-Chief
References 1. Letterman D. Brainy Quote. Available at: http:// www.brainyquote.com/quotes/quotes/d/davidlette102678. Accessed 15 September 2015. 2. Brophy RH, Gefen AM, Matava MJ, Wright RW, Smith MV. Understanding of meniscus injury and expectations of meniscus surgery in patients presenting for orthopaedic care. Arthroscopy 2015;31:2295-2300. 3. Rossi MJ, Guttmann D, MacLennan MJ, Lubowitz JH. Video informed consent improves knee arthroscopy patient comprehension. Arthroscopy 2005;21:739-743. 4. Black EM, Warner JJP. 5 Points on value in orthopaedic Surgery. Am J Orthop 2013;42:22-25. 5. Black EM, Higgins LD, Warner JJP. Value-based shoulder surgery: Practicing outcomes-driven, cost-conscious care. J Shoulder Elbow Surg 2013;22:1000-1009. 6. Hamid KS, Nwachukwu BU, Poehling GG. Lights, camera action: How to make arthroscopy a star in value-based health care. Arthroscopy 2013;29:1900-1901. 7. Lubowitz JH, Provencher MT, Poehling GG. Measuring orthopaedic outcome: Shoulder outcome measures. Arthroscopy 2013;29:791-793.
8. Harris JD, Cvetanovich G, Erickson BJ, et al. Current status of evidence-based sports medicine. Arthroscopy 2014;30:362-371. 9. Porter ME. A strategy for health care reform-toward a value-based system. N Engl J Med 2009;361:109-112. 10. Warner JJP. Defining value in shoulder care: What you should know in 2014. Presented at the 2014 Annual Meeting of the Arthroscopy Association of North American, Hollywood, Florida. 11. Henn RF III, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am 2007;89:1913-1919. 12. Mahomed NN, Liang MH, Cook EF, et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol 2002;29:1273-1279. 13. Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall Award: Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 2006;452: 35-43. 14. Yee A, Adjei N, Do J, Ford M, Finkelstein J. Do patient expectations of spinal surgery relate to functional outcome? Clin Orthop Relat Res 2008;466:1154-1161. 15. Rosenberger PH, Jokl P, Cameron A, Ickovics JR. Shared decision making, preoperative expectations, and postoperative reality: Differences in physician and patient predictions and ratings of knee surgery outcomes. Arthroscopy 2005;21:562-569. 16. Tokish JT. Collecting outcomes data: Why it is important and how to do it. Presented at the 2015 Annual Meeting of the Arthroscopy Association of North American, Los Angeles, California. 17. Wuerz TH. Current health care policies and their impact on your practice. Patient-centered outcomes collections in orthopedics: Why is this important? Presented at the 2015 Annual Meeting of the Arthroscopy Association of North American, Los Angeles, California. 18. Lubowitz JH, Smith P. Current concepts in clinical research: Web-based, automated, arthroscopic surgery prospective database registry. Arthroscopy 2012;28: 425-428. 19. Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patientcentered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2014;31:454-459. 20. Steadman JR, Matheny LM, Hurst JM, Briggs KK. Patient-centered outcomes and revision rate in patients undergoing ACL reconstruction using bone-patellar tendon-bone autograft compared with bone-patellar tendon-bone allograft: A matched case-control study. Arthroscopy 2015;31:2320-2326. 21. Rogers FB, Krasne M, Bradburn E, et al. Acute care and trauma surgeons: We can’t get no satisfactiondWhat do satisfaction surveys measure? Am Surg 2012;78:731-734. 22. Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Arthroscopic arthritis options are on the horizon. Arthroscopy 2015;31:389-392. 23. Kibler WB, Sciascia AD. Current practice for the diagnosis of a superior labral anterior to posterior (SLAP) lesion: Systematic review and physician survey. Arthroscopy 2015;31:2456-2469.
The Expectation Game: Patient Comprehension Is a Determinant of Outcome
Abstract: Patient comprehension of orthopaedic procedures is low and their expectations for successful outcomes are often unrealistic. Surgeons need to understand this and guide patients toward sensible expectations.
USA Today has come out with a new surveydapparently, three out of every four people make up 75% of the population.1 David Letterman
S
urveys frequently tell us what is blatantly obvious. Rarely, they surprise us. On certain occasions, however, their conclusionsddespite being expectedddrive home a point to which we must listen. The value of survey studies can be called into question because of their inherent lower level of evidence; generally, as readers may have noticed, we do not list a level of evidence in reports of surveys of patients for this very reason, and surveys of surgeons are listed as Level V evidence, the lowest level. There are times, however, when the results of a survey should be highlighted. In this month’s issue, Brophy, Gefen, Matava, Wright, and Smith from Washington University in St. Louis report on their study of patients presenting to orthopaedic clinics, regardless of complaint, with regard to their understanding of arthroscopic meniscus surgery.2 The results: a typical patient has no better chance than a flip of a coin to correctly answer factual questions about meniscus surgery. In addition, patients have a complete misunderstanding of the incidence of meniscus repair versus meniscectomy; patients believe that repair is the most common treatment. We commend the authors for appropriately developing a survey questionnaire with a sixth-grade reading level, which reminds us of the often marked disparity between provider and patient. Recall that in addition to misconception, patients face challenges of comprehension with verbal communication of informed consent (when compared with video, which is still not perfect3). On a positive note, this past research showed that we Ó 2015 by the Arthroscopy Association of North America 0749-8063/15908/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.09.005
can improve patient comprehension, but it requires an effort, such as preparation of audiovisual aids. One might ask, “Why is this important?” or better yet, “Why does this matter so long as patients improve?” This is important because a patient’s improvement is an expectation game. In today’s age of outcome-driven performance and increased reliance on value-based medicine,4-8 understanding patients’ comprehension is of utmost importance. We are reminded that value is the simple quotient of outcome divided by cost.9 While costs can be estimated, the determination of outcome proves challenging; as J.J.P. Warner expressed critically in 2014 at the AANA Annual Meeting, “We don’t measure our outcomes and we have a poor consensus on outcomes measures.”10 In addition, outcome goals for one condition of one patient may be vastly different from another patient with the same condition. Patientreported outcome is personal, and individual patient expectations have a significant effect on the outcome of arthroscopy, including rotator cuff surgery, joint arthroplasty, and lumbar spine surgery.11-15 Thus, addressing patient expectations can be an important start. Notably, AANA and other orthopaedic societies now diligently strive to refine and implement prospective outcome measurement.16-20 Patients’ understanding, and thus their expectations, not only reflect accordingly on outcome measures, but have a direct impact on satisfaction surveys like the Press Ganey Survey. These surveys rank our performance, and they can and will be used for incentivebased pay. This is already being implemented despite evidence that a “patient’s underlying clinical condition may influence response to patient satisfaction surveys,” and the lack of any proof that this correlates with physician competence.21 In orthopaedic surgery, particularly arthroscopic surgery, we have the unique yet onerous task of treating pain and function. Patients often expect zero rather than
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 12 (December), 2015: pp 2283-2284
2283
2284
EDITORIAL
less pain and normal rather than improved function. We need to shift our patients away from these impractical beliefs to a more realistic understanding; a joint can be made better but not necessarily normal. As we have said before, this task also entails educating our primarycare colleagues, our legislature, and the press.22 But first, let us educate ourselves about our patients and what they know. Then we need to temper our own expectations of our patients’ outcome, because we can often be our own worst enemy; we should not assign personal blame for less than perfect results when perfect results do not exist. This issue also highlights another survey that deserves attention; Kibler and Sciascia23 supplement their systematic review of current practice for diagnosis of SLAP lesions with a survey of surgeon expert opinion (Level V evidence). Level V evidence has great value when systematic review of the literature fails to resolve a controversy, and where the literature is of poor methodological quality. The level of evidence assigned to Kibler and Sciascia’s article is according to the systematic review (Level IV evidence), as the Level V adjunctive survey requires no level of evidence, and seems more of a bonus than the primary research method. We point out this technicality just in case our argument above skewed reader expectations. Michael J. Rossi, M.D. Deputy Editor Jefferson C. Brand, M.D. Deputy Editor Matthew T. Provencher, M.D. Assistant Editor-in-Chief James H. Lubowitz, M.D. Editor-in-Chief
References 1. Letterman D. Brainy Quote. Available at: http:// www.brainyquote.com/quotes/quotes/d/davidlette102678. Accessed 15 September 2015. 2. Brophy RH, Gefen AM, Matava MJ, Wright RW, Smith MV. Understanding of meniscus injury and expectations of meniscus surgery in patients presenting for orthopaedic care. Arthroscopy 2015;31:2295-2300. 3. Rossi MJ, Guttmann D, MacLennan MJ, Lubowitz JH. Video informed consent improves knee arthroscopy patient comprehension. Arthroscopy 2005;21:739-743. 4. Black EM, Warner JJP. 5 Points on value in orthopaedic Surgery. Am J Orthop 2013;42:22-25. 5. Black EM, Higgins LD, Warner JJP. Value-based shoulder surgery: Practicing outcomes-driven, cost-conscious care. J Shoulder Elbow Surg 2013;22:1000-1009. 6. Hamid KS, Nwachukwu BU, Poehling GG. Lights, camera action: How to make arthroscopy a star in value-based health care. Arthroscopy 2013;29:1900-1901. 7. Lubowitz JH, Provencher MT, Poehling GG. Measuring orthopaedic outcome: Shoulder outcome measures. Arthroscopy 2013;29:791-793.
8. Harris JD, Cvetanovich G, Erickson BJ, et al. Current status of evidence-based sports medicine. Arthroscopy 2014;30:362-371. 9. Porter ME. A strategy for health care reform-toward a value-based system. N Engl J Med 2009;361:109-112. 10. Warner JJP. Defining value in shoulder care: What you should know in 2014. Presented at the 2014 Annual Meeting of the Arthroscopy Association of North American, Hollywood, Florida. 11. Henn RF III, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am 2007;89:1913-1919. 12. Mahomed NN, Liang MH, Cook EF, et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol 2002;29:1273-1279. 13. Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall Award: Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 2006;452: 35-43. 14. Yee A, Adjei N, Do J, Ford M, Finkelstein J. Do patient expectations of spinal surgery relate to functional outcome? Clin Orthop Relat Res 2008;466:1154-1161. 15. Rosenberger PH, Jokl P, Cameron A, Ickovics JR. Shared decision making, preoperative expectations, and postoperative reality: Differences in physician and patient predictions and ratings of knee surgery outcomes. Arthroscopy 2005;21:562-569. 16. Tokish JT. Collecting outcomes data: Why it is important and how to do it. Presented at the 2015 Annual Meeting of the Arthroscopy Association of North American, Los Angeles, California. 17. Wuerz TH. Current health care policies and their impact on your practice. Patient-centered outcomes collections in orthopedics: Why is this important? Presented at the 2015 Annual Meeting of the Arthroscopy Association of North American, Los Angeles, California. 18. Lubowitz JH, Smith P. Current concepts in clinical research: Web-based, automated, arthroscopic surgery prospective database registry. Arthroscopy 2012;28: 425-428. 19. Ferro FP, Ho CP, Briggs KK, Philippon MJ. Patientcentered outcomes after hip arthroscopy for femoroacetabular impingement and labral tears are not different in patients with normal, high, or low femoral version. Arthroscopy 2014;31:454-459. 20. Steadman JR, Matheny LM, Hurst JM, Briggs KK. Patient-centered outcomes and revision rate in patients undergoing ACL reconstruction using bone-patellar tendon-bone autograft compared with bone-patellar tendon-bone allograft: A matched case-control study. Arthroscopy 2015;31:2320-2326. 21. Rogers FB, Krasne M, Bradburn E, et al. Acute care and trauma surgeons: We can’t get no satisfactiondWhat do satisfaction surveys measure? Am Surg 2012;78:731-734. 22. Lubowitz JH, Provencher MT, Brand JC, Rossi MJ. Arthroscopic arthritis options are on the horizon. Arthroscopy 2015;31:389-392. 23. Kibler WB, Sciascia AD. Current practice for the diagnosis of a superior labral anterior to posterior (SLAP) lesion: Systematic review and physician survey. Arthroscopy 2015;31:2456-2469.