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The expectations of patients who undergo surgery for stress incontinence
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UROGYNECOLOGY
The expectations of patients who undergo surgery for stress incontinence Veronica T. Mallett, MD; Linda Brubaker, MD, MS; Anne M. Stoddard, ScD; Diane Borello-France, PhD; Sharon Tennstedt, PhD; Lynn Hall, RN; Lee Hammontree, MD; for the Urinary Incontinence Treatment Network OBJECTIVE: The purpose of this study was to assess patient expectations of surgical outcome after preoperative counseling of surgical procedures in a randomized trial of 655 women in a comparison of the rectus fascial sling and Burch colposuspension. STUDY DESIGN: Women who selected surgery for treating stress in-
continence and who consented to this randomized, surgical trial completed a preoperative questionnaire to assess expectations for the postsurgical effects of surgery on urinary incontinence-related symptoms, limitations, and emotions. Associations of expectations with a range of preoperative urinary incontinence measures were explored.
(72%), and urgency (70%). Sexual and social limitations were less frequent (ⱕ44%). Treatment expectations were higher for women who reported more symptom bother. As expected, most women (98%) had an expectation that urine leakage would be completely or almost completely eliminated. However, most women (92%) who reported urgency or frequency (83%) expected significant improvement of these symptoms after surgery. CONCLUSION: Patients who undergo stress incontinence surgery have high expectations regarding the outcome of incontinence surgery, which include the resolution of urgency and frequency.
RESULTS: The most frequent preoperative symptoms were urine leak-
age (98%), embarrassment (88%), frequency (74%), physical activity
Key words: informed consent, patient expectation, surgical outcome
Cite this article as: Mallett VT, Brubaker L, Stoddard AM, et at. The expectations of patients who undergo surgery for stress incontinence. Am J Obstet Gynecol 2008;198:308.e1-308.e6.
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urgery is considered to be highly effective for resolving urodynamic stress incontinence.1,2 The physician’s definition of success, however, may not account for the patient’s entire experience, particularly with complications, side effects, or new/persistent pelvic floor symptoms. Previous investigators observed that women who ex-
perience ⬎1 preoperative urinary symptom may expect that stress incontinence surgery will resolve all urinary symptoms.3,4 When these symptoms are not resolved, the patient may consider her surgery to be ineffective or unsuccessful. Despite efforts to align physician and patient expectations, all experienced clinicians recognize that
From the Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN (Dr Mallett); the Departments of Obstetrics and Gynecology and Urology, Loyola University Medical Center, Maywood, IL (Dr Brubaker); New England Research Institutes, Watertown, MA (Drs Stoddard and Tennstedt); the Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA (Dr Borello-France); Kaiser Permanente, San Diego, CA (Ms Hall); and the Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, AL (Dr Hammontree). Received March 30, 2007; accepted Sept. 2, 2007. Reprints: Veronica T. Mallett, MD, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Regional Medical Center, 853 Jefferson, Memphis, TN 38138; [email protected]. Supported by cooperative agreements from the National Institute of Diabetes and Digestive and Kidney Diseases, with additional support from the National Institute of Child Health and Human Development and the Office of Research on Women’s Health, National Institutes of Health (U01 DK58225, U01 DK58234, U01 DK58229, U01 DK58231, U01 DK60397, U01 DK60401, U01 DK60395, U01 DK60393, U01 DK60380, U01 DK60379) 0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2007.09.003
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this is an area that needs further work.5-7 We sought to understand more fully the patterns of expectations of surgical patients and to correlate these patterns with more conventional measures, including validated condition-specific quality of life questionnaires, with a population of women who participated in a randomized surgical trial of stress incontinence. Potential variables that were thought to be related to preoperative expectations included sociodemographic characteristics, health status, urinary incontinence (UI) type and severity, UI symptom-related distress, and UI-related quality of life.
M ATERIALS AND M ETHODS Design Baseline information from 655 women who were enrolled in the Stress Incontinence Surgery Efficacy study (SISTEr trial; a randomized clinical trial to compare the Burch colposuspension and the rectus fascial sling procedures) was analyzed. Briefly, the SISTEr study enrolled
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www.AJOG.org women who had predominate stress UI with symptoms of at least a 3-month duration, evidence of urethral hypermobility, and urine loss on provocative bladder stress test. The study design, including baseline and follow-up measurements, was published previously.8 All study participants provided written informed consent for the study. The Institutional Review Board at each participating center reviewed and approved the study protocol. Each patient had an informed consent discussion regarding stress incontinence surgery with her surgeon as part of her routine clinical care. The standard components of informed consent include the purpose, risks, benefits, complications, and alternatives of the procedure. This discussion was tailored individually to each participant, based on her planned surgery. Each patient made a clinical decision to proceed with stress incontinence surgery on the basis of her individual surgeon’s counseling. Before consent for stress incontinence surgery, patients were shown a standard video as part of their informed consent discussion regarding research participation. This 10minute videotape presented a standard description of the SISTEr trial that explained the study aims; the similarities and differences, risks, and success rates of the 2 surgical procedures; the randomization and informed consent processes, and the schedule and type of evaluations that are associated with study participation. Before consent for research participation, subjects underwent a standard baseline expectations assessment that has been described previously.8
Measures of preoperative expectations Preoperative expectations of surgery were measured with a questionnaire that was developed specifically for this study, the Incontinence Surgical Expectations Questionnaire (ISEQ). The ISEQ includes 9 items across 3 domains: symptoms, activities (physical and social), and emotions. Four items refer to surgical expectations for improving UI symptoms; 4 items pertain to activity limita-
tion expectations, and 1 item concerns emotional expectations. A 5-point Likert-type scale of responses is used to rate the expectations for each symptom (1 [no better] to 5 [completely better]), activity limitation (1 [no more capable] to 5 [completely capable]), and emotion (1 [no less bothered] to 5 [completely not bothered]) that are associated with UI. We also asked which 1 symptom or activity women expected to improve the most as a result of surgery. The openended responses were postcoded into categories that reflected the most commonly mentioned responses. To assess each woman’s overall expectations, we computed the average of the expectations for the symptoms or limitations that she identified as problems. The expectation scores were highly skewed, with most women reporting high expectations. We therefore dichotomized the expectation scores into 2 categories. Scores of ⱖ4 were considered “high expectations,” and scores of ⬍4 were considered “low expectations.” Internal consistency and test-retest reliability for the ISEQ were tested in a sample of 25 women in a separate pilot study that was conducted at 1 of the Urinary Incontinence Treatment Network sites.9 The total scale Cronbach’s alpha (without the sexual limitation item because of low response frequency) was high (alpha ⫽ .86), with individual itemtotal correlations ranging from 0.46 to 0.86. Test-retest agreement (mean retest interval, 6.5 ⫾ 3.7 days) for the presence or absence of symptoms, limitations, and emotional bother ranged from 82%94%. Agreement between test and retest responses ranged from 67% (frequency) to 82% (urgency) for expectations of symptom relief and from 67% (physical activity) to 100% (both social and sexual activity) for resolution of activity limitations; agreement was 77% for change in emotions.
Other measures Symptoms of UI were assessed with the use of the Medical, Epidemiologic, and Social Aspects of Aging Questionnaire.10 This measure includes a 9-item subscale for stress-type symptoms and a 6-item
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subscale for urge-type symptoms. An index for each type of symptom converted the scores to scales that ranged from 0-100. Inclusion criteria for this trial required that the stress index had to exceed the urge index. Severity of incontinence was defined by the average number of incontinence episodes per day collected by a 3-day bladder diary and pad test weight (grams).11 Demographic data included age, race/ethnicity, occupation, and socioeconomic status. The Nam-PowersTerrie Occupational Status Score was used as a measure of socioeconomic status.12 It measures occupational status on the basis of educational requirements and expected salary. Scores range from 0-100; a higher score indicates greater status. Health status data included body mass index, past treatment or surgery for UI, and Valsalva leak point pressure. Also included were 2 health status subscales from the Medical Outcomes Study 36item short-form health survey: the physical function and role-physical subscales.13 The Medical Outcomes Study 36-item short-form health survey is a measure of health-related quality of life in chronic disorders. Higher scores indicate fewer physical or role functioning limitations. Symptom distress/bother and quality of life related to UI symptoms were measured with the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ), respectively.14 The UDI contains 19 symptoms (across 3 symptom domains: irritative, obstructive/discomfort, and stress) that are associated with lower urinary tract dysfunction. Respondents are asked to rate the degree of bother that is associated with each symptom that they have experienced on a scale from 1 (not at all) to 4 (greatly). UDI scores range from 0-300; higher scores indicate greater symptom-related distress.2 The IIQ is a 30-item questionnaire that measures the impact of UI on various activities, roles, and emotional states. The scores range from 0-400; a higher score indicates poorer perceived UI-related quality of life.
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TABLE 1
Selected characteristics of study participants (n ⴝ 654) Characteristic
Mean ⴞ SD
Range
Age (y)
51.9 ⫾ 10.3
27-81
Mean body mass index (kg/m )
30.0 ⫾ 6.1
18-54
Occupational status
56.9 ⫾ 24.6
3-99
N
%
.............................................................................................................................................................................................................................................. 2 .............................................................................................................................................................................................................................................. a ..............................................................................................................................................................................................................................................
Medical Outcomes Study 36-item short-form health survey scoreb
..............................................................................................................................................................................................................................................
Physical function
58.1 ⫾ 27.7
0-100
Role: physical
53.5 ⫾ 41.7
0-100
measure that was hypothesized to be associated with expectations. For categoric explanatory variables, we used crossclassification and the chi-square test of association. For continuous measures, we tested the difference of means by the analysis of variance. All analyses were conducted with the personal computer version of SAS Statistical Software (version 9.2; SAS Institute Inc, Cary, NC).
.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Race/ethnicity
.....................................................................................................................................................................................................................................
Hispanic
72
11
480
73
.....................................................................................................................................................................................................................................
Non-Hispanic white
.....................................................................................................................................................................................................................................
Non-Hispanic black
44
7
58
9
..............................................................................................................................................................................................................................................
Other
.............................................................................................................................................................................................................................................. a
Scores range from 0 to 100; a higher score indicates greater status.
b
Higher score indicates fewer physical or role functioning limitations.10
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
Analysis We computed descriptive statistics for the symptoms and the expectations for surgical resolution of each symptom that
was reported and the frequency of women with high and low overall expectations. We then examined the bivariate associations of expectation with each
R ESULTS Women in this study were predominantly white (73%), middle-aged (average, 52 years), and socioeconomically diverse (Table 1). On average, they reported 3.2 incontinent episodes per day. By design, all women had stress UI, but most of them (93%) also reported some degree of urge UI symptoms. The mean body mass index was 30 kg/m2, which indicated that the woman was generally overweight. Table 2 shows the percentage of women who reported each symptom and activity that were limited by incon-
TABLE 2
Frequency of symptoms and related treatment expectations: results from the ISEQ
ISEQ domain and questions
Women who answered “yes” (%)
Expectation (Percent of women who answered “yes” and reported high expectations)9
Symptoms
.......................................................................................................................................................................................................................................................................................................................................................................
Do you currently experience any of the compared with symptoms?
.......................................................................................................................................................................................................................................................................................................................................................................
Urine leakage
98
98
.......................................................................................................................................................................................................................................................................................................................................................................
An urgency to urinate such that you fear not making it to the bathroom in time
70
92
Frequent urination
74
83
Any other symptoms
26
93
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Activities
.......................................................................................................................................................................................................................................................................................................................................................................
Do you currently limit any of the listed activities because of your bladder?
.......................................................................................................................................................................................................................................................................................................................................................................
Physical activities (eg, housework, yard work, going for a walk, dancing, jogging, golfing)
72
93
.......................................................................................................................................................................................................................................................................................................................................................................
Social activities (eg, visiting friends, vacationing, going to church or temple)
33
88
Sexual activity
44
87
Any other activities
22
92
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Emotional
.......................................................................................................................................................................................................................................................................................................................................................................
Are you bothered by feelings of embarrassment, helplessness, frustration, and/or depression because of your bladder problems? Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
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TABLE 3
TABLE 4
Characteristics of incontinence
Symptom expected to improve the most from surgery
Variable
Mean ⴞ SD
Range
Symptomsa
Symptom or limitation
Percent
Stress subscale percentage
71.6 ⫾ 17.0
15-100
Physical activities
27.0
Urge subscale percentage
36.0 ⫾ 21.7
0-94
Urine leakage
23.5
3.2 ⫾ 2.9
0-26
Bother by negative emotions
17.6
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Incontinence severity (mean episodes per day on 3-day diary)
.............................................................................................................................................................................................................................................. b
UDI
..............................................................................................................................................................................................................................................
151.1 ⫾ 48.6
0-290
Obstructive
25.1 ⫾ 21.7
0-97
Irritative
47.8 ⫾ 25.2
0-100
Stress
78.1 ⫾ 21.9
0-100
Total
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. c
IIQ
..............................................................................................................................................................................................................................................
Total
171.1 ⫾ 101.2
..............................................................................................................................................................................................................................................
Activity
45.3 ⫾ 27.8
0-400
Travel
39.3 ⫾ 29.3
0-100
Social
36.4 ⫾ 26.8
Emotional
50.5 ⫾ 28.2
Pad weight (g)
43.5 ⫾ 79.4
........................................................................................................... ........................................................................................................... ...........................................................................................................
Other
...........................................................................................................
Cough, sneeze, laugh
5.6
Use of pads
5.1
Sexual activity
3.7
........................................................................................................... ........................................................................................................... ...........................................................................................................
Other: lifestyle
2.8
Frequency
2.6
Urgency
2.0
Other: prolapse
1.9
........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................
Social activities
1.7
6.0
0-100
Other: mixed, none, unknown
0-100
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
...........................................................................................................
..............................................................................................................................................................................................................................................
Mean Valsalva leak point pressure, unreduced
116.55 ⫾ 37.5
29.7-244.3
..............................................................................................................................................................................................................................................
Ninety-three women (14%) had had previous upper intestinal surgery. a
Medical, Epidemiologic, and Social Aspects of Aging Questionnaire.6
b
Scores range from 0-300; higher scores indicate greater symptom-related distress.11
c
Scores range from 0-400; a higher score indicates poorer perceived quality of life.
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
tinence. The most frequent symptoms were urine leakage (98%), urinary frequency (74%), and urinary urgency (70%). Most women reported embarrassment (88%). Limitations on physical activities (72%) were common, with 44% reporting limitations in sexual and social activities. Expectations of surgical outcomes were high. When the responses to the individual items were combined, the mean and median ISEQ scores were 4.4 of 5, and 87% of women had a score of ⱖ4. All women who reported urinary leakage expected near or complete resolution of this symptom. However, most of these women also expected relief of symptoms that were not associated with stress UI. Of the 70% of patients who reported urgency, nearly all (92%) expected that the stress incontinence surgery would improve urgency. Similarly, of the 74% of patients who re-
ported urinary frequency, 83% expected substantial symptom relief. Incontinence characteristics included the average number of incontinent episodes per day based on the 3-day diary, pad weight, Valsalva leak point pressure, and previous antiincontinence operative procedures (Table 3). Based on bivariate analysis (not shown), there was no relationship between surgical expectation and any of the incontinence characteristics. Expectations also were not related to preoperative functional health status, age, previous antiincontinence surgery, or physical examination parameters. When testing the bivariate association of each of the potential explanatory variables in relation to the level (low vs high) of overall surgical expectations, we found that only the UDI stress subscale and the IIQ travel subscale were associated significantly with surgical expecta-
tions. That is, women with high expectations reported greater UI-related distress but lower impact of UI on travel. Among women with low expectations, the mean UDI stress score was 71.5 ⫾ 23.1; among women with high expectations, the mean score was 79.3 ⫾ 21.2 (P ⫽ .002). Regarding the IIQ-travel subscale, women with low expectations reported a mean impact of 46.4 ⫾ 28.4, compared with a mean impact of 38.7 ⫾ 29.3 for women with high expectations (P ⫽ .02) The frequencies of the responses to the open-ended question, “Of all the symptoms, lifestyle restrictions, or emotions that you experience because of your bladder problem, which one problem do you expect to improve the most after you recover from your surgery?” are shown in Table 4. The 3 most common responses were problems with physical activities (27%), urine leakage (24%), and bother from negative emotions (18%).
C OMMENT Patients had very high expectations for their individual surgical outcomes, especially those women who reported more symptom bother. Ninety-eight percent of respondents indicated that urine leakage was a problem, and 98% of them ex-
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pected to be either completely symptom free or much better after surgery. This is an expectation that continence surgeons find reasonable for an individual woman, although all continence surgeons are aware of that surgical success rates are not this high overall for a surgical population. It is understandable that an individual woman who is planning surgery expects that she will have a successful outcome. Clearly, if she did not have this expectation, it would be unreasonable for her to proceed with surgery. However, continence surgeons generally do not believe that urinary urgency and/or frequency is a predictable outcome of stress incontinence surgery. It is assumed that surgeons do not suggest improvements with urinary urgency and/or frequency as a result of stress incontinence surgery. Some surgeons are quite strong in counseling that these symptoms are quite certain to persist. Nonetheless, individual surgical patients do expect resolution of these symptoms as well. This finding of mismatched expectations has important implications for preoperative patient counseling. Clinical counseling (as represented over 9 clinical sites and 22 surgeons) seems ineffective in setting clinically reasonable preoperative expectations regarding urgency and frequency. In addition to this routine preoperative clinical counseling, the patients in our study had a preoperative consultation that included a videotaped description of the surgical procedures, the efficacy of both procedures, and the type of incontinence that the surgery was designed to address. Yet, despite preoperative consultation that included the study-related videotape, patients had high expectations for the resolution of urinary urgency and frequency symptoms. Only 2.4% of the open-ended responses identified frequency as the most important expectation. However, 83% of participants who reported urgency and frequency on the ISEQ expected these symptoms to be resolved by the surgical intervention. This discordance has several possible explanations. Although patients were told clearly the nature of the antiincontinence surgery, the surgeons failed to educate these patients effectively about the 308.e5
www.AJOG.org distinction between irritative symptoms and symptoms of stress incontinence. Surgical counseling may include a great deal of information, including health information, logistical information, and financial information. Unpalatable aspects (such as persistent symptoms) may be lost selectively to recall. In addition, patients may not have attended to, processed, and/or remembered the information. Even in the confines of a randomized, highly standardized clinical trial, ethical care of research participants requires individualized conversations between a patient and her surgeon. A limitation of our findings includes the possibility that surgeons in this trial may have underemphasized the possibility of persistent symptoms during counseling of these procedures. Alternatively, patients may have understood the nature of their condition and the limitations of the antiincontinence surgeries but rejected the physician’s prognostic statements regarding irritative symptoms and maintained an optimistic expectation, knowing that their chance of irritative symptom resolution was low. It has been suggested that inappropriate expectations can arise from a person’s previous experiences of surgery, from similar experiences for other successful interventions, or from word of mouth from friends with whom the patient discussed the procedure or plans to undergo the procedure.15 Patient satisfaction is related directly to patient expectation of treatment outcome.16 Patients with inappropriate treatment expectations may be at increased risk for dissatisfaction with optimal care. Therefore, it is problematic when patient and surgeons have discordant expectations. To reduce this discordance, further research will need to identify whether mismatched expectations are a result of insufficient information, ineffective counseling methods, or individual characteristics that predispose patients to disregard information. More effective communication is essential.17 The SISTEr trial will also provide information that will allow us to investigate patient expectations in relation to surgical outcome and patient satisfaction with
American Journal of Obstetrics & Gynecology MARCH 2008
outcome at the conclusion of the study to determine whether this surgical cohort is similar to others that were reported previously.18 We observed a strong relationship between UI bother and level of treatment expectation as expected. We found the relationship between treatment expectation and the IIQ travel score is somewhat unexpected. We hypothesize that the impact of incontinence on travel is so significant that patients see the ability to return to travel as unrealistic. Our ability to fully investigate factors that are related to low expectations is limited by the skewness of the responses to the ISEQ scale. The clustering of the open-ended responses around the established domains for the ISEQ supports the construct validity of the questionnaire. The skewed range of responses is problematic when one searches for correlates. This limitation is not a reflection of the usefulness of the questionnaire but more likely a reflection of the fact that, for patients to undergo surgery, they must expect a positive outcome. In addition, we did not evaluate a patient’s knowledge of her condition or of the 2 surgeries. We also did not measure selfefficacy (one’s belief that one can exercise control over health and health habits) as a potential predictor or determinant of expectations. Bandura’s19 social cognitive theory posits that self-efficacy, outcome expectations, and perceived facilitators and impediments to change influence the health goals that an individual establishes and the behaviors that an individual adopts and maintains. Self-efficacy has been shown to affect outcome expectations in several disease states.19,20 The role of self-efficacy in a patient’s expectations of continence surgery must be explored. In addition, there is a possible selection bias. Baseline data on the expectations of women with stress incontinence who underwent a surgical intervention yet elected not to participate in the trial are not available. Women who are willing to participate in a randomized surgical trial may have different expectations about outcomes than a general urogynecology population. Finally, the predominantly white study population obviously affects
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www.AJOG.org the extent to which these data can be generalized to other populations. Multicentered recruitment in 9 areas of the country does help support the applicability of the results to a wide portion of the US female population who will undergo stress incontinence surgery. The results of this study support the importance of assessment of the efficacy of a variety of counseling methods to improve patient recall, comprehension, and ease of understanding. Verifying the patient’s preoperative understanding of the condition, limitations of surgery, risks, and potential complications should help surgeons modify unrealistic expectations of treatment outcome.21,22 In turn, realistic treatment expectations may impact patient satisfaction directly with the outcome of surgical intervention. f REFERENCES 1. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol 1998;160:1312-6. 2. Ostergard DR. Primary slings for everyone with genuine stress incontinence? The argument against Int Urgynecol J Pelvic Floor Dysfunct 1997;8:321-2. 3. Elkadry EA, Kenton KS, FitzGerald MP, Shott S, Brubaker L. Patient-selected goals: a new perspective on surgical outcome. Am J Obstet Gynecol 2003;189:1551-8. 4. Mahajan ST, Elkadry EA, Kenton KS, Shott S, Brubaker L. Patient-centered surgical outcomes: the impact of goal achievement and
urge incontinence on patient satisfaction one year after surgery. Am J Obstet Gynecol 2006;194:722-8. 5. 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. 6. Jones KR, Burney RE, Christy B. Patient expectations for surgery: are they being met? J Qual Improve 2000;26:349-60. 7. McKinley RK, Stevenson K, Adams S, Manku-Scott TK. Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care? Fam Pract 2002;19:333-8. 8. Tennstedt S. Urinary Incontinence Treatment Network: design of the stress incontinence surgical treatment efficacy trial (SISTEr). Urology 2005;66:1213-7. 9. Borello-France D, Zyczynski H, Mallett V, Tennstedt S, FitzGerald M, for the Urinary Incontinence Treatment Network. Patient expectations and satisfaction following surgery for stress incontinence [abstract]. American Urogynecologic Society Meeting, San Francisco, CA. 2002 10. Herzog AR, Diokno AC, Brown MB, Normolle DP, Brock BM. Two-year incidence, remission, and change patterns of urinary incontinence in non-institutionalized older adults. J Gerontol 1990;45:M67-74.:16. 11. Richter H, Burgio K, Brubaker L, et al; for the Urinary Incontinence Treatment Network. Factors associated with incontinence frequency in a surgical cohort f stress incontinent women. Am J Obstet Gynecol 2005;193: 2088-93. 12. Nam CB, Terrie EW. 1980-based NamPowers occupational status scores: 1988 Working Paper 38-48. Tallahassee (FL): Center for the Study of Population, Florida State University; 1988.
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13. Ware JE Jr, Sherbourne CD. The MOS 36item short-form health survey (SF-36): conceptual framework and item selection. Med Care 1992;30:473-83. 14. Shumaker SA, Wyman Uebersax JS, McClish D, Fantl JA. Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory: Continence Program in Women Research group. Qual Life Res 1994;3:291-306. 15. Iversen MD, Daltroy LH, Fossel AH, Katz JN. The prognostic importance of patient preoperative expectations of surgery for lumbar spinal stenosis. Patient Educ Council 1998; 34:169-78. 16. Nettleman MD. Patient satisfaction: what’s mew? Clin Perform Qual Health Care 1998; 6:33-7. 17. Douglas TS, Mann NH, Hodge AL. Evaluation of preoperative patient education and computer assisted instructions. J Spinal Disord 1998;11:28-35. 18. Peck BM, Asch DA, Gool SD, et al. Measuring patient expectations: does the instrument affect satisfaction or expectations? Med Care 2001;39:100-8. 19. Bandura A. Self efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:181-97. 20. Carrol DL. The importance of self efficacy in elderly patients recovering from coronary artery bypass surgery. Heart Lung 1995;24:50-9. 21. Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes JAMA 2001;16555:174-9. 22. Lutz GK, Butzlaff ME, Atlas SJ, et al. The relationship between expectations and outcomes in surgery for sciatica. J Gen Intern Med 1999;14:740-4.
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UROGYNECOLOGY
The expectations of patients who undergo surgery for stress incontinence Veronica T. Mallett, MD; Linda Brubaker, MD, MS; Anne M. Stoddard, ScD; Diane Borello-France, PhD; Sharon Tennstedt, PhD; Lynn Hall, RN; Lee Hammontree, MD; for the Urinary Incontinence Treatment Network OBJECTIVE: The purpose of this study was to assess patient expectations of surgical outcome after preoperative counseling of surgical procedures in a randomized trial of 655 women in a comparison of the rectus fascial sling and Burch colposuspension. STUDY DESIGN: Women who selected surgery for treating stress in-
continence and who consented to this randomized, surgical trial completed a preoperative questionnaire to assess expectations for the postsurgical effects of surgery on urinary incontinence-related symptoms, limitations, and emotions. Associations of expectations with a range of preoperative urinary incontinence measures were explored.
(72%), and urgency (70%). Sexual and social limitations were less frequent (ⱕ44%). Treatment expectations were higher for women who reported more symptom bother. As expected, most women (98%) had an expectation that urine leakage would be completely or almost completely eliminated. However, most women (92%) who reported urgency or frequency (83%) expected significant improvement of these symptoms after surgery. CONCLUSION: Patients who undergo stress incontinence surgery have high expectations regarding the outcome of incontinence surgery, which include the resolution of urgency and frequency.
RESULTS: The most frequent preoperative symptoms were urine leak-
age (98%), embarrassment (88%), frequency (74%), physical activity
Key words: informed consent, patient expectation, surgical outcome
Cite this article as: Mallett VT, Brubaker L, Stoddard AM, et at. The expectations of patients who undergo surgery for stress incontinence. Am J Obstet Gynecol 2008;198:308.e1-308.e6.
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urgery is considered to be highly effective for resolving urodynamic stress incontinence.1,2 The physician’s definition of success, however, may not account for the patient’s entire experience, particularly with complications, side effects, or new/persistent pelvic floor symptoms. Previous investigators observed that women who ex-
perience ⬎1 preoperative urinary symptom may expect that stress incontinence surgery will resolve all urinary symptoms.3,4 When these symptoms are not resolved, the patient may consider her surgery to be ineffective or unsuccessful. Despite efforts to align physician and patient expectations, all experienced clinicians recognize that
From the Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN (Dr Mallett); the Departments of Obstetrics and Gynecology and Urology, Loyola University Medical Center, Maywood, IL (Dr Brubaker); New England Research Institutes, Watertown, MA (Drs Stoddard and Tennstedt); the Department of Physical Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, PA (Dr Borello-France); Kaiser Permanente, San Diego, CA (Ms Hall); and the Department of Urology, University of Alabama at Birmingham School of Medicine, Birmingham, AL (Dr Hammontree). Received March 30, 2007; accepted Sept. 2, 2007. Reprints: Veronica T. Mallett, MD, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Regional Medical Center, 853 Jefferson, Memphis, TN 38138; [email protected]. Supported by cooperative agreements from the National Institute of Diabetes and Digestive and Kidney Diseases, with additional support from the National Institute of Child Health and Human Development and the Office of Research on Women’s Health, National Institutes of Health (U01 DK58225, U01 DK58234, U01 DK58229, U01 DK58231, U01 DK60397, U01 DK60401, U01 DK60395, U01 DK60393, U01 DK60380, U01 DK60379) 0002-9378/$34.00 • © 2008 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2007.09.003
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this is an area that needs further work.5-7 We sought to understand more fully the patterns of expectations of surgical patients and to correlate these patterns with more conventional measures, including validated condition-specific quality of life questionnaires, with a population of women who participated in a randomized surgical trial of stress incontinence. Potential variables that were thought to be related to preoperative expectations included sociodemographic characteristics, health status, urinary incontinence (UI) type and severity, UI symptom-related distress, and UI-related quality of life.
M ATERIALS AND M ETHODS Design Baseline information from 655 women who were enrolled in the Stress Incontinence Surgery Efficacy study (SISTEr trial; a randomized clinical trial to compare the Burch colposuspension and the rectus fascial sling procedures) was analyzed. Briefly, the SISTEr study enrolled
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www.AJOG.org women who had predominate stress UI with symptoms of at least a 3-month duration, evidence of urethral hypermobility, and urine loss on provocative bladder stress test. The study design, including baseline and follow-up measurements, was published previously.8 All study participants provided written informed consent for the study. The Institutional Review Board at each participating center reviewed and approved the study protocol. Each patient had an informed consent discussion regarding stress incontinence surgery with her surgeon as part of her routine clinical care. The standard components of informed consent include the purpose, risks, benefits, complications, and alternatives of the procedure. This discussion was tailored individually to each participant, based on her planned surgery. Each patient made a clinical decision to proceed with stress incontinence surgery on the basis of her individual surgeon’s counseling. Before consent for stress incontinence surgery, patients were shown a standard video as part of their informed consent discussion regarding research participation. This 10minute videotape presented a standard description of the SISTEr trial that explained the study aims; the similarities and differences, risks, and success rates of the 2 surgical procedures; the randomization and informed consent processes, and the schedule and type of evaluations that are associated with study participation. Before consent for research participation, subjects underwent a standard baseline expectations assessment that has been described previously.8
Measures of preoperative expectations Preoperative expectations of surgery were measured with a questionnaire that was developed specifically for this study, the Incontinence Surgical Expectations Questionnaire (ISEQ). The ISEQ includes 9 items across 3 domains: symptoms, activities (physical and social), and emotions. Four items refer to surgical expectations for improving UI symptoms; 4 items pertain to activity limita-
tion expectations, and 1 item concerns emotional expectations. A 5-point Likert-type scale of responses is used to rate the expectations for each symptom (1 [no better] to 5 [completely better]), activity limitation (1 [no more capable] to 5 [completely capable]), and emotion (1 [no less bothered] to 5 [completely not bothered]) that are associated with UI. We also asked which 1 symptom or activity women expected to improve the most as a result of surgery. The openended responses were postcoded into categories that reflected the most commonly mentioned responses. To assess each woman’s overall expectations, we computed the average of the expectations for the symptoms or limitations that she identified as problems. The expectation scores were highly skewed, with most women reporting high expectations. We therefore dichotomized the expectation scores into 2 categories. Scores of ⱖ4 were considered “high expectations,” and scores of ⬍4 were considered “low expectations.” Internal consistency and test-retest reliability for the ISEQ were tested in a sample of 25 women in a separate pilot study that was conducted at 1 of the Urinary Incontinence Treatment Network sites.9 The total scale Cronbach’s alpha (without the sexual limitation item because of low response frequency) was high (alpha ⫽ .86), with individual itemtotal correlations ranging from 0.46 to 0.86. Test-retest agreement (mean retest interval, 6.5 ⫾ 3.7 days) for the presence or absence of symptoms, limitations, and emotional bother ranged from 82%94%. Agreement between test and retest responses ranged from 67% (frequency) to 82% (urgency) for expectations of symptom relief and from 67% (physical activity) to 100% (both social and sexual activity) for resolution of activity limitations; agreement was 77% for change in emotions.
Other measures Symptoms of UI were assessed with the use of the Medical, Epidemiologic, and Social Aspects of Aging Questionnaire.10 This measure includes a 9-item subscale for stress-type symptoms and a 6-item
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subscale for urge-type symptoms. An index for each type of symptom converted the scores to scales that ranged from 0-100. Inclusion criteria for this trial required that the stress index had to exceed the urge index. Severity of incontinence was defined by the average number of incontinence episodes per day collected by a 3-day bladder diary and pad test weight (grams).11 Demographic data included age, race/ethnicity, occupation, and socioeconomic status. The Nam-PowersTerrie Occupational Status Score was used as a measure of socioeconomic status.12 It measures occupational status on the basis of educational requirements and expected salary. Scores range from 0-100; a higher score indicates greater status. Health status data included body mass index, past treatment or surgery for UI, and Valsalva leak point pressure. Also included were 2 health status subscales from the Medical Outcomes Study 36item short-form health survey: the physical function and role-physical subscales.13 The Medical Outcomes Study 36-item short-form health survey is a measure of health-related quality of life in chronic disorders. Higher scores indicate fewer physical or role functioning limitations. Symptom distress/bother and quality of life related to UI symptoms were measured with the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ), respectively.14 The UDI contains 19 symptoms (across 3 symptom domains: irritative, obstructive/discomfort, and stress) that are associated with lower urinary tract dysfunction. Respondents are asked to rate the degree of bother that is associated with each symptom that they have experienced on a scale from 1 (not at all) to 4 (greatly). UDI scores range from 0-300; higher scores indicate greater symptom-related distress.2 The IIQ is a 30-item questionnaire that measures the impact of UI on various activities, roles, and emotional states. The scores range from 0-400; a higher score indicates poorer perceived UI-related quality of life.
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TABLE 1
Selected characteristics of study participants (n ⴝ 654) Characteristic
Mean ⴞ SD
Range
Age (y)
51.9 ⫾ 10.3
27-81
Mean body mass index (kg/m )
30.0 ⫾ 6.1
18-54
Occupational status
56.9 ⫾ 24.6
3-99
N
%
.............................................................................................................................................................................................................................................. 2 .............................................................................................................................................................................................................................................. a ..............................................................................................................................................................................................................................................
Medical Outcomes Study 36-item short-form health survey scoreb
..............................................................................................................................................................................................................................................
Physical function
58.1 ⫾ 27.7
0-100
Role: physical
53.5 ⫾ 41.7
0-100
measure that was hypothesized to be associated with expectations. For categoric explanatory variables, we used crossclassification and the chi-square test of association. For continuous measures, we tested the difference of means by the analysis of variance. All analyses were conducted with the personal computer version of SAS Statistical Software (version 9.2; SAS Institute Inc, Cary, NC).
.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Race/ethnicity
.....................................................................................................................................................................................................................................
Hispanic
72
11
480
73
.....................................................................................................................................................................................................................................
Non-Hispanic white
.....................................................................................................................................................................................................................................
Non-Hispanic black
44
7
58
9
..............................................................................................................................................................................................................................................
Other
.............................................................................................................................................................................................................................................. a
Scores range from 0 to 100; a higher score indicates greater status.
b
Higher score indicates fewer physical or role functioning limitations.10
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
Analysis We computed descriptive statistics for the symptoms and the expectations for surgical resolution of each symptom that
was reported and the frequency of women with high and low overall expectations. We then examined the bivariate associations of expectation with each
R ESULTS Women in this study were predominantly white (73%), middle-aged (average, 52 years), and socioeconomically diverse (Table 1). On average, they reported 3.2 incontinent episodes per day. By design, all women had stress UI, but most of them (93%) also reported some degree of urge UI symptoms. The mean body mass index was 30 kg/m2, which indicated that the woman was generally overweight. Table 2 shows the percentage of women who reported each symptom and activity that were limited by incon-
TABLE 2
Frequency of symptoms and related treatment expectations: results from the ISEQ
ISEQ domain and questions
Women who answered “yes” (%)
Expectation (Percent of women who answered “yes” and reported high expectations)9
Symptoms
.......................................................................................................................................................................................................................................................................................................................................................................
Do you currently experience any of the compared with symptoms?
.......................................................................................................................................................................................................................................................................................................................................................................
Urine leakage
98
98
.......................................................................................................................................................................................................................................................................................................................................................................
An urgency to urinate such that you fear not making it to the bathroom in time
70
92
Frequent urination
74
83
Any other symptoms
26
93
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Activities
.......................................................................................................................................................................................................................................................................................................................................................................
Do you currently limit any of the listed activities because of your bladder?
.......................................................................................................................................................................................................................................................................................................................................................................
Physical activities (eg, housework, yard work, going for a walk, dancing, jogging, golfing)
72
93
.......................................................................................................................................................................................................................................................................................................................................................................
Social activities (eg, visiting friends, vacationing, going to church or temple)
33
88
Sexual activity
44
87
Any other activities
22
92
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Emotional
.......................................................................................................................................................................................................................................................................................................................................................................
Are you bothered by feelings of embarrassment, helplessness, frustration, and/or depression because of your bladder problems? Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
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95
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TABLE 3
TABLE 4
Characteristics of incontinence
Symptom expected to improve the most from surgery
Variable
Mean ⴞ SD
Range
Symptomsa
Symptom or limitation
Percent
Stress subscale percentage
71.6 ⫾ 17.0
15-100
Physical activities
27.0
Urge subscale percentage
36.0 ⫾ 21.7
0-94
Urine leakage
23.5
3.2 ⫾ 2.9
0-26
Bother by negative emotions
17.6
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Incontinence severity (mean episodes per day on 3-day diary)
.............................................................................................................................................................................................................................................. b
UDI
..............................................................................................................................................................................................................................................
151.1 ⫾ 48.6
0-290
Obstructive
25.1 ⫾ 21.7
0-97
Irritative
47.8 ⫾ 25.2
0-100
Stress
78.1 ⫾ 21.9
0-100
Total
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. c
IIQ
..............................................................................................................................................................................................................................................
Total
171.1 ⫾ 101.2
..............................................................................................................................................................................................................................................
Activity
45.3 ⫾ 27.8
0-400
Travel
39.3 ⫾ 29.3
0-100
Social
36.4 ⫾ 26.8
Emotional
50.5 ⫾ 28.2
Pad weight (g)
43.5 ⫾ 79.4
........................................................................................................... ........................................................................................................... ...........................................................................................................
Other
...........................................................................................................
Cough, sneeze, laugh
5.6
Use of pads
5.1
Sexual activity
3.7
........................................................................................................... ........................................................................................................... ...........................................................................................................
Other: lifestyle
2.8
Frequency
2.6
Urgency
2.0
Other: prolapse
1.9
........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................
Social activities
1.7
6.0
0-100
Other: mixed, none, unknown
0-100
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
...........................................................................................................
..............................................................................................................................................................................................................................................
Mean Valsalva leak point pressure, unreduced
116.55 ⫾ 37.5
29.7-244.3
..............................................................................................................................................................................................................................................
Ninety-three women (14%) had had previous upper intestinal surgery. a
Medical, Epidemiologic, and Social Aspects of Aging Questionnaire.6
b
Scores range from 0-300; higher scores indicate greater symptom-related distress.11
c
Scores range from 0-400; a higher score indicates poorer perceived quality of life.
Mallett. Patient expectations of incontinence surgery. Am J Obstet Gynecol 2008.
tinence. The most frequent symptoms were urine leakage (98%), urinary frequency (74%), and urinary urgency (70%). Most women reported embarrassment (88%). Limitations on physical activities (72%) were common, with 44% reporting limitations in sexual and social activities. Expectations of surgical outcomes were high. When the responses to the individual items were combined, the mean and median ISEQ scores were 4.4 of 5, and 87% of women had a score of ⱖ4. All women who reported urinary leakage expected near or complete resolution of this symptom. However, most of these women also expected relief of symptoms that were not associated with stress UI. Of the 70% of patients who reported urgency, nearly all (92%) expected that the stress incontinence surgery would improve urgency. Similarly, of the 74% of patients who re-
ported urinary frequency, 83% expected substantial symptom relief. Incontinence characteristics included the average number of incontinent episodes per day based on the 3-day diary, pad weight, Valsalva leak point pressure, and previous antiincontinence operative procedures (Table 3). Based on bivariate analysis (not shown), there was no relationship between surgical expectation and any of the incontinence characteristics. Expectations also were not related to preoperative functional health status, age, previous antiincontinence surgery, or physical examination parameters. When testing the bivariate association of each of the potential explanatory variables in relation to the level (low vs high) of overall surgical expectations, we found that only the UDI stress subscale and the IIQ travel subscale were associated significantly with surgical expecta-
tions. That is, women with high expectations reported greater UI-related distress but lower impact of UI on travel. Among women with low expectations, the mean UDI stress score was 71.5 ⫾ 23.1; among women with high expectations, the mean score was 79.3 ⫾ 21.2 (P ⫽ .002). Regarding the IIQ-travel subscale, women with low expectations reported a mean impact of 46.4 ⫾ 28.4, compared with a mean impact of 38.7 ⫾ 29.3 for women with high expectations (P ⫽ .02) The frequencies of the responses to the open-ended question, “Of all the symptoms, lifestyle restrictions, or emotions that you experience because of your bladder problem, which one problem do you expect to improve the most after you recover from your surgery?” are shown in Table 4. The 3 most common responses were problems with physical activities (27%), urine leakage (24%), and bother from negative emotions (18%).
C OMMENT Patients had very high expectations for their individual surgical outcomes, especially those women who reported more symptom bother. Ninety-eight percent of respondents indicated that urine leakage was a problem, and 98% of them ex-
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pected to be either completely symptom free or much better after surgery. This is an expectation that continence surgeons find reasonable for an individual woman, although all continence surgeons are aware of that surgical success rates are not this high overall for a surgical population. It is understandable that an individual woman who is planning surgery expects that she will have a successful outcome. Clearly, if she did not have this expectation, it would be unreasonable for her to proceed with surgery. However, continence surgeons generally do not believe that urinary urgency and/or frequency is a predictable outcome of stress incontinence surgery. It is assumed that surgeons do not suggest improvements with urinary urgency and/or frequency as a result of stress incontinence surgery. Some surgeons are quite strong in counseling that these symptoms are quite certain to persist. Nonetheless, individual surgical patients do expect resolution of these symptoms as well. This finding of mismatched expectations has important implications for preoperative patient counseling. Clinical counseling (as represented over 9 clinical sites and 22 surgeons) seems ineffective in setting clinically reasonable preoperative expectations regarding urgency and frequency. In addition to this routine preoperative clinical counseling, the patients in our study had a preoperative consultation that included a videotaped description of the surgical procedures, the efficacy of both procedures, and the type of incontinence that the surgery was designed to address. Yet, despite preoperative consultation that included the study-related videotape, patients had high expectations for the resolution of urinary urgency and frequency symptoms. Only 2.4% of the open-ended responses identified frequency as the most important expectation. However, 83% of participants who reported urgency and frequency on the ISEQ expected these symptoms to be resolved by the surgical intervention. This discordance has several possible explanations. Although patients were told clearly the nature of the antiincontinence surgery, the surgeons failed to educate these patients effectively about the 308.e5
www.AJOG.org distinction between irritative symptoms and symptoms of stress incontinence. Surgical counseling may include a great deal of information, including health information, logistical information, and financial information. Unpalatable aspects (such as persistent symptoms) may be lost selectively to recall. In addition, patients may not have attended to, processed, and/or remembered the information. Even in the confines of a randomized, highly standardized clinical trial, ethical care of research participants requires individualized conversations between a patient and her surgeon. A limitation of our findings includes the possibility that surgeons in this trial may have underemphasized the possibility of persistent symptoms during counseling of these procedures. Alternatively, patients may have understood the nature of their condition and the limitations of the antiincontinence surgeries but rejected the physician’s prognostic statements regarding irritative symptoms and maintained an optimistic expectation, knowing that their chance of irritative symptom resolution was low. It has been suggested that inappropriate expectations can arise from a person’s previous experiences of surgery, from similar experiences for other successful interventions, or from word of mouth from friends with whom the patient discussed the procedure or plans to undergo the procedure.15 Patient satisfaction is related directly to patient expectation of treatment outcome.16 Patients with inappropriate treatment expectations may be at increased risk for dissatisfaction with optimal care. Therefore, it is problematic when patient and surgeons have discordant expectations. To reduce this discordance, further research will need to identify whether mismatched expectations are a result of insufficient information, ineffective counseling methods, or individual characteristics that predispose patients to disregard information. More effective communication is essential.17 The SISTEr trial will also provide information that will allow us to investigate patient expectations in relation to surgical outcome and patient satisfaction with
American Journal of Obstetrics & Gynecology MARCH 2008
outcome at the conclusion of the study to determine whether this surgical cohort is similar to others that were reported previously.18 We observed a strong relationship between UI bother and level of treatment expectation as expected. We found the relationship between treatment expectation and the IIQ travel score is somewhat unexpected. We hypothesize that the impact of incontinence on travel is so significant that patients see the ability to return to travel as unrealistic. Our ability to fully investigate factors that are related to low expectations is limited by the skewness of the responses to the ISEQ scale. The clustering of the open-ended responses around the established domains for the ISEQ supports the construct validity of the questionnaire. The skewed range of responses is problematic when one searches for correlates. This limitation is not a reflection of the usefulness of the questionnaire but more likely a reflection of the fact that, for patients to undergo surgery, they must expect a positive outcome. In addition, we did not evaluate a patient’s knowledge of her condition or of the 2 surgeries. We also did not measure selfefficacy (one’s belief that one can exercise control over health and health habits) as a potential predictor or determinant of expectations. Bandura’s19 social cognitive theory posits that self-efficacy, outcome expectations, and perceived facilitators and impediments to change influence the health goals that an individual establishes and the behaviors that an individual adopts and maintains. Self-efficacy has been shown to affect outcome expectations in several disease states.19,20 The role of self-efficacy in a patient’s expectations of continence surgery must be explored. In addition, there is a possible selection bias. Baseline data on the expectations of women with stress incontinence who underwent a surgical intervention yet elected not to participate in the trial are not available. Women who are willing to participate in a randomized surgical trial may have different expectations about outcomes than a general urogynecology population. Finally, the predominantly white study population obviously affects
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www.AJOG.org the extent to which these data can be generalized to other populations. Multicentered recruitment in 9 areas of the country does help support the applicability of the results to a wide portion of the US female population who will undergo stress incontinence surgery. The results of this study support the importance of assessment of the efficacy of a variety of counseling methods to improve patient recall, comprehension, and ease of understanding. Verifying the patient’s preoperative understanding of the condition, limitations of surgery, risks, and potential complications should help surgeons modify unrealistic expectations of treatment outcome.21,22 In turn, realistic treatment expectations may impact patient satisfaction directly with the outcome of surgical intervention. f REFERENCES 1. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol 1998;160:1312-6. 2. Ostergard DR. Primary slings for everyone with genuine stress incontinence? The argument against Int Urgynecol J Pelvic Floor Dysfunct 1997;8:321-2. 3. Elkadry EA, Kenton KS, FitzGerald MP, Shott S, Brubaker L. Patient-selected goals: a new perspective on surgical outcome. Am J Obstet Gynecol 2003;189:1551-8. 4. Mahajan ST, Elkadry EA, Kenton KS, Shott S, Brubaker L. Patient-centered surgical outcomes: the impact of goal achievement and
urge incontinence on patient satisfaction one year after surgery. Am J Obstet Gynecol 2006;194:722-8. 5. 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. 6. Jones KR, Burney RE, Christy B. Patient expectations for surgery: are they being met? J Qual Improve 2000;26:349-60. 7. McKinley RK, Stevenson K, Adams S, Manku-Scott TK. Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care? Fam Pract 2002;19:333-8. 8. Tennstedt S. Urinary Incontinence Treatment Network: design of the stress incontinence surgical treatment efficacy trial (SISTEr). Urology 2005;66:1213-7. 9. Borello-France D, Zyczynski H, Mallett V, Tennstedt S, FitzGerald M, for the Urinary Incontinence Treatment Network. Patient expectations and satisfaction following surgery for stress incontinence [abstract]. American Urogynecologic Society Meeting, San Francisco, CA. 2002 10. Herzog AR, Diokno AC, Brown MB, Normolle DP, Brock BM. Two-year incidence, remission, and change patterns of urinary incontinence in non-institutionalized older adults. J Gerontol 1990;45:M67-74.:16. 11. Richter H, Burgio K, Brubaker L, et al; for the Urinary Incontinence Treatment Network. Factors associated with incontinence frequency in a surgical cohort f stress incontinent women. Am J Obstet Gynecol 2005;193: 2088-93. 12. Nam CB, Terrie EW. 1980-based NamPowers occupational status scores: 1988 Working Paper 38-48. Tallahassee (FL): Center for the Study of Population, Florida State University; 1988.
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