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Expectations and Outcomes in Cataract Surgery
A Prospective Test of 2 Models of Satisfaction
Chet K. Pager, BMed (Hons), DipEd, MA
Arch Ophthalmol. 2004;122:1788-1792.
ABSTRACT
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Objectives To document patients’ preoperative expectations for postoperative outcomes. To measure the relative contribution of patient understanding, expectations, outcome, and expectation-outcome discrepancy in determining patient satisfaction.
Methods One hundred twenty-one patients were surveyed just before and 1 month after cataract surgery regarding their understanding of the procedure, satisfaction with their vision, and both current and expected visual function for each of the items on the Visual Function Index (VF-14).
Results Sixty percent of patients expected to achieve a perfect VF-14 score. The average expected VF-14 score was 96.1, compared with an achieved VF-14 score of just 89.8. The most unrealistic expectations involved driving at night, reading small print, and doing fine handiwork. Surprisingly, improvement in visual function was not correlated with satisfaction in vision. While patient understanding, expectations, and achieved VF-14 score did correlate with satisfaction, when controlling for other factors, only achievement-expectation discrepancy was independently predictive.
Conclusions This study provides support for the expectation-outcome discrepancy model of patient satisfaction. Further, it highlights the highly unrealistic expectations harbored by patients with cataract and emphasizes the importance for physicians to control their patients’ expectations. Controlling patient expectations may be more effective than improving patients’ postoperative outcome in terms of maximizing patient satisfaction.
INTRODUCTION
Patient satisfaction is an increasingly important objective for health services.1-2 This trend reflects the reality that the choice and success of many treatments are based on subjective patient-defined criteria2-4; that patient satisfaction is an element of health status itself,5-6 with satisfied patients reporting greater compliance, well-being, and treatment outcomes7-9; that health care is increasingly embracing principles of consumerism and autonomy1, 10; that health care is becoming increasingly privatized and economically competitive,11-12 with satisfied patients both remaining with and recommending their provider7, 13-15; and that a satisfied patient is the best defense against malpractice lawsuits.11
The dominant theoretical model of satisfaction involves meeting patient expectations, that is, minimizing the expectation-outcome discrepancy. This conception of satisfaction has been variously reported as its actual definition11, 16-17 or its primary causal factor.4, 10-11,18 Suggested mechanisms for this effect include cognitive dissonance, patient conditioning, memory and symptom reporting, and anxiety.19-20
However, the importance of expectation-outcome congruence has not always been borne out empirically,19, 21-22 with the actual (perceived) outcome18, 23 or expectations alone via the placebo effect10, 20, 24 accounting for most of a patient’s satisfaction in some studies. Additionally, the extent to which patients feel adequately informed about their illness has been frequently demonstrated as an important and independent determinant of patient satisfaction.1, 25
Cataract surgery has increased 400% during the last 10 years26 to become the most common surgical procedure in the developed world,27 exceeding 1.6 million operations in the United States alone28 because of an aging population29-30 and dramatic expansion of indications following improvements in technology.31-32 Visual acuity is no longer considered a useful measure of need for surgery,33-34 with patient concern, lifestyle, and subjective reports of function being the primary factors for referral.35-36 Furthermore, cataract surgery is predominantly delivered through the private health care sector,31 where patient satisfaction is of particular consequence.
However, patient satisfaction has rarely been considered in cataract surgery,34, 37 and no studies have addressed the role of the hypothesized determinants of patient satisfaction. The objectives of this study are first, to document patients’ preoperative expectations for postoperative outcomes and second, to measure the relative contribution of patient understanding, expectations, outcome, and expectation-outcome discrepancy in determining patient satisfaction.
METHODS
PATIENTS
One hundred sixty consecutive patients undergoing day-stay cataract surgery at Sydney Private Hospital, Sydney, Australia, were invited to participate in this study when first registering at the hospital for their surgery. Sydney Private Hospital is the largest private provider of cataract surgery in New South Wales and serves a large cross-section of patients from throughout metropolitan Sydney. Institutional review board and hospital approval were obtained.
PROCEDURE AND MEASURES
After obtaining informed consent, the patient’s age, sex, visual acuity, and current visual function were recorded by a research interviewer, along with the amount of information the patient had already received regarding this surgery. Visual function was measured using the Visual Function Index (VF-14),38-39 a widely used scale based on trouble conducting common binocular activities, with final score ranging from 0 (no visual ability) to 100 (no visual disability). Patients were then asked to rate their expected postoperative functional outcome for each of the 14 items on the VF-14 scale. As part of a related investigation, patients were shown a short video describing either the anatomy of cataract or the procedures experienced during the cataract surgery itself. Neither video concerned the postoperative outcomes or expectations that are the subject of this study. All the data collection occurred 2 to 4 hours prior to surgery but before the instillation of eye drops, changing of clothes, or any clinical induction beyond the registration forms.
On hospital discharge, patients were given an addressed, postage-paid envelope containing a questionnaire to be completed 1 month after surgery. This questionnaire included the VF-14 and the opportunity for patients to rate their degree of understanding and overall satisfaction on a 12-cm visual analog scale. Patients who did not return their questionnaires were reminded by a follow-up telephone call, and an additional questionnaire and reply envelope were provided if required.
DATA ANALYSIS
The visual analog scale markings were converted into a scale of 0 to 10, and all data were double entered and verified using an Excel spreadsheet, then converted into SPSS for Windows version 11 (SPSS Inc, Chicago, Ill) for further analysis.
Spearman rank correlations were used to measure the relationship between overall satisfaction and aspects of expected or achieved visual function (each item of the VF-14 is recorded on a 5-point ordinal scale). A multiple regression was used to measure the isolated contribution of postoperative function, improvement, and expectation-outcome discrepancy toward predicting satisfaction, while controlling for the other factors. Finally, both Mann-Whitney U and 2-tailed, independent-sample t tests were used to ensure that the preoperative video content had no influence on any of the measured outcomes.
RESULTS
One hundred sixty patients were approached, and 141 (88%) agreed to participate. Of these, 121 (85%) returned their 1-month questionnaire. There were no differences in preoperative characteristics between these 121 patients and those who were lost to follow-up (Mann-Whitney U and t tests not shown). The basic preoperative and postoperative characteristics of these patients are presented in Table 1. The mean (SD) age was 73.8 (9.2) years, 91 (64.5%) patients were female, 55 (39%) patients had previous cataract surgery, and the median visual acuity was 6/18 in the operative and 6/10 in the nonoperative eye, with a mean (SD) preoperative VF-14 score of 84.7 (14.8) and postoperative VF-14 score of 89.8 (16.4). There were no preoperative or postoperative differences on any measure based on video content (Mann-Whitney U and t tests not shown).
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Table 1. Patient Characteristics
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PREOPERATIVE EXPECTATIONS
Patients had very high expectations for postoperative function, expecting to achieve a mean (SD) VF-14 score of 96.1 (10.3), representing near-perfect vision and an 11-point expected gain. Eighty-four patients (60%) expected to achieve a perfect VF-14 score of 100. Only 18 patients did not expect at least some VF-14 improvement, 12 because their preoperative VF-14 score was already 100; the other 6 all had preoperative VF-14 scores higher than 90 and expected the same VF-14 score postoperatively.
Table 2 presents for each item of the VF-14 scale the expected amount of improvement and the expectation-outcome discrepancy. Driving at night, reading small print, doing fine handiwork, and reading a newspaper or book are the items for which patients expected the greatest degree of improvement and for which, not unexpectedly, patients’ actual outcomes were the furthest from what they expected. The average expectation-outcome discrepancy was 6.3 points, with 80 patients (66%) failing to equal or exceed their expectations at 1-month follow-up.
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Table 2. Expected Improvement and Expectation-Outcome Discrepancy for Visual Function Index (VF-14) Items
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Table 3 presents the correlations between patient satisfaction and either actual outcome or expectation-outcome discrepancy for each item on the VF-14 scale. Actual outcome and satisfaction were significantly correlated with 11 VF-14 items and more strongly than the 6 VF-14 items for which expectation-outcome discrepancy and satisfaction were correlated.
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Table 3. Spearman Rank Correlations With Patient Satisfaction for Visual Function Index (VF-14) Items*
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Table 4 presents the correlations between patient satisfaction and overall expected improvement, actual improvement, actual outcome, and expectation-outcome discrepancy. Actual outcome was marginally better correlated than achievement-outcome discrepancy (0.32 vs 0.28), and the degree of improvement was not significantly related to patient satisfaction at all.
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Table 4. Spearman Correlations With Patient Satisfaction for Composite Measures
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Table 5 presents a multiple regression of the significant predictors of patient satisfaction. When controlling for each other, only the expectation-outcome discrepancy was a significant independent determinant of patient satisfaction (standardized  = –0.30; P = .04). Multiple regressions with other configurations of predictor variables consistently returned expectation-outcome discrepancy as the only independently predictive factor of patient satisfaction.
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Table 5. Multiple Regression of Predictors of Patient Satisfaction
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PATIENT INFORMATION
Before the operation, the majority of patients (115 [81%]) felt at the time of operation that they "learned as much as I wanted to know" and only 19 (13%) felt that they’d like to have been told more. At 1 month, the first group’s mean (SD) overall satisfaction was 8.0 (2.0), which was not significantly different from the second group’s satisfaction of 7.9 (2.0) by Mann-Whitney U test, nor were preoperative information and 1-month postoperative satisfaction significantly correlated. However, the patients’ responses to this preoperative question about information were narrowly distributed and temporally distant from the 1-month postoperative question about satisfaction.
More significantly, patients’ response to the question "how well did you understand what was happening to you" at 1 month after surgery (mean [SD] 8.0 [2.0]) was strongly correlated with patients’ postoperative satisfaction ( = 0.56; P<.001).
COMMENT
The results of this study lend support to the applicability of the expectation-outcome discrepancy model of patient satisfaction in the context of day-stay cataract surgery. Importantly, the improvement in visual function experienced by a patient did not at all significantly correlate with overall satisfaction, a finding that runs counter to common expectations. However, expected improvement, actual outcome, and expectation-outcome discrepancy were all moderately correlated with satisfaction. Clearly, patient satisfaction is a complex and multidimensional construct that cannot be explained by a single variable.7, 10, 24 However, it is worth noting that when controlling for other factors, neither actual improvement nor actual outcome were predictive of patient satisfaction, while the expectation-outcome discrepancy was.
These findings further reinforce the only previous study to formally document patient expectations,40 demonstrating that patient expectations are unreasonably high and few patients realistically achieve them. In short, 70-year-old patients expect cataract surgery to allow them to see like 20-year-olds, although at this age there are inevitably other factors beside cataract that will impair their vision to some degree. It is not surprising that ocular comorbidity is a major predictor of patient dissatisfaction with cataract surgery.41-42
As with the previous study, reading small print, doing fine handiwork, and reading a newspaper were the most likely areas of high expectations for improvement (as well as disappointment with outcome). For our sample, driving at night was also a source of unrealistic and unfulfilled expectations for the 34 patients (24%) who did so.
Patients’ perceived level of understanding at 1 month was strongly correlated with satisfaction. Some part of this correlation may be owing to an overarching response bias toward visual analog scales presented at the same sitting, despite the fact that the questions were presented as clearly independent and visual analog scales have been shown to be both reliable and valid measures in similar contexts.43-44 Additionally, the correlation between perceived understanding and satisfaction supplies no evidence as to the direction of causation. Nonetheless, it is likely that perceived understanding, as with expectation-outcome discrepancy, is an important component of patient satisfaction.
Although the strength of correlations was modest, explaining just 4% to 17% of the variance (r2), they were strongly significant and consistent in magnitude with other studies of satisfaction, the determination of which is highly multifactorial. We must also acknowledge that the difference between interviewer-assisted preoperative and self-administered postoperative questionnaires may affect the scores obtained, although this difference was consistent across all patients and should not affect the findings of this study. Furthermore, the VF-14 in particular has been extensively validated and found to be both stable and reliable across a wide range of contexts.38-39 This study did not investigate the changing trajectory of patient expectations across time prior to surgery, nor the impact on satisfaction on the tiny minority who experienced operative complications. Further research into these subsidiary questions could provide a more nuanced view of the relationship between expectations, outcome, and satisfaction.
To provide the highest level of satisfaction, health care professionals must control their patients’ expectations and understanding of treatment,11 and the close relationship between accurate patient expectations and adequate informed consent cannot be ignored.40 In fact, to improve patient satisfaction, health care professionals would be advised to pay more attention to patient understanding and expectations, even at the expense of improving patient outcome. In this study, the degree of improvement in visual function was not significantly correlated with patient satisfaction at all.
This study highlights the particular areas where greater attention to informing patients’ preoperative expectations would be warranted, as well as important rationales for doing so. Finally, this study strongly supports the proposition that perceived patient understanding and expectation-outcome discrepancy are important factors in overall patient satisfaction.
AUTHOR INFORMATION
Correspondence: Chet K. Pager, BMed (Hons), DipEd, MA, 67 Missenden Rd PO, Royal Prince Albert Hospital, Camperdown NSW 2050, Australia (ckpager{at}stanfordalumni.org).
Submitted for Publication: October 1, 2003; final revision received March 29, 2004; accepted June 29, 2004.
Funding/Support: This study was supported in part by the National Health and Medical Research Council of Australia, Canberra.
Financial Disclosure: None.
Author Affiliation: Department of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, Australia.
REFERENCES
| |
1. Scott A, Smith RD. Keeping the customer satisfied: issues in the interpretation and use of patient satisfaction surveys. Int J Qual Health Care. 1994;6:353-359.
FREE FULL TEXT
2. Epstein AM. The outcomes movement: will it get us where we want to go? N Engl J Med. 1990;323:266-270.
ISI
| PUBMED
3. Feinstein AR, Josephy BR, Wells CK. Scientific and clinical problems in indexes of functional disability. Ann Intern Med. 1986;105:413-420.
4. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality of care. Inquiry. 1988;25:25-36.
ISI
| PUBMED
5. Fitzpatrick R. Survey of patient satisfaction, I: important general considerations. BMJ. 1991;302:887-889.
6. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260:1743-1748.
ABSTRACT
7. Aharony L, Strasser S. Patient satisfaction: what we know about and what we still need to explore. Med Care Rev. 1993;50:49-79.
PUBMED
8. Padberg RM, Padberg LF. Strengthening the effectiveness of patient education: applied principles of adult education. Oncol Nurs Forum. 1990;17:65-69.
PUBMED
9. Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med. 1988;27:637-644.
10. Williams B. Patient satisfaction: a valid concept? Soc Sci Med. 1994;38:509-516.
11. Yucelt U. An investigation of causes of patient satisfaction/dissatisfaction with physician services. Health Mark Q. 1994;12:11-28.
PUBMED
12. Angelopoulou P, Kangis P, Babis G. Private and public medicine: a comparison of quality perceptions. Int J Health Care Qual Assur Inc Leadersh Health Serv. 1998;11:14-20.
PUBMED
13. Ware JE, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann. 1983;6:291-297.
FULL TEXT
| PUBMED
14. Rubin HR, Gandek B, Rogers WH, Kosinski M, McHorney CA, Ware JE. Patients' ratings of outpatient visits in different practice settings: results from the Medical Outcomes Study. JAMA. 1993;270:835-840.
ABSTRACT
15. Rubin HR. Can patients evaluate the quality of hospital care? Med Care Rev. 1990;47:267-326.
PUBMED
16. Zeithaml VA, Parasuraman A, Berry LL. Delivering Quality Service: Balancing Customer Perceptions and Expectations. New York, NY: T Free Press; 1990.
17. Messner RL, Lewis SJ. Increasing Patient Satisfaction: A Guide for Nurses. New York, NY: Springer; 1996.
18. Carr-Hill RA. The measurement of patient satisfaction. J Public Health Med. 1992;14:236-249.
FREE FULL TEXT
19. Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127-141.
FREE FULL TEXT
20. Flood AB, Lorence DP, Ding J, McPherson K, Black NA. The role of expectations in patients' reports of post-operative outcomes and improvement following therapy. Med Care. 1993;31:1043-1056.
FULL TEXT
|
ISI
| PUBMED
21. Fitzpatrick R, Hopkins A. Problems in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illn. 1983;5:297-311.
FULL TEXT
| PUBMED
22. Draper M, Hill S. The Role of Patient Satisfaction Surveys in a National Approach to Hospital Quality Management. Melbourne: Australian Government Publishing Service; 1995.
23. Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16:577-582.
24. Linder-Pelz S. Social psychological determinants of patient satisfaction: a test of five hypotheses. Soc Sci Med. 1982;16:583-589.
25. Egbert LD, Battit GE, Welch CE, et al. Reeducation of post-operative pain: encouragement and instruction to patients. N Engl J Med. 1964;270:825-827.
26. Taylor HR. Cataract: how much surgery do we have to do? Br J Ophthalmol. 2000;84:1-2.
FREE FULL TEXT
27. Westcott MC, Tuft SJ, Minassian DC. Effect of age on visual outcome following cataract extraction. Br J Ophthalmol. 2000;84:1380-1382.
FREE FULL TEXT
28. American Academy of Ophthalmology. Preferred Practice Pattern: Cataract in the Adult Eye. San Francisco, Calif: American Academy of Ophthalmology; 2001:8.
29. McCarty CA, Keeffe JE, Taylor HR. The need for cataract surgery: projections based on lens opacity, visual acuity, and personal concern. Br J Ophthalmol. 1999;83:62-65.
FREE FULL TEXT
30. World Health Organization. Global Initiative for the Elimination of Avoidable Blindness: An Informal Consultation. Geneva, Switzerland: World Health Organization; 1997. WHO/PBL/97.61.
31. Keeffe JE, Taylor HR. Cataract surgery in Australia 1985-94. Aust N Z J Ophthalmol. 1996;24:313-317.
ISI
| PUBMED
32. Batterbury M, Khaw PT, Hands R, et al. The cataract explosion: the changing pattern of diagnoses of patients attending an ophthalmic outpatient department. Eye. 1991;5:369-372.
33. Friedman DS, Schein OD. Assessing disability in the patient with cataract. Curr Opin Ophthalmol. 1998;9:1-4.
PUBMED
34. Legro MW. Quality of life and cataracts: a review of patient-centered studies of cataract surgery outcomes. Ophthalmic Surg. 1991;22:431-443.
ISI
| PUBMED
35. McCarty CA, Nanjan MB, Taylor HR. Operated and unoperated cataract in Australia. Clin Experiment Ophthalmol. 2000;28:77-82.
FULL TEXT
|
ISI
| PUBMED
36. Keeffe JE, McCarty CA, Chang WP, Steinberg EP, Taylor HR. Relative importance of visual acuity, patient concern and patient lifestyle on referral for cataract surgery [ARVO abstract 871]. Invest Ophthalmol Vis Sci. 1996;37:S183.
37. Mangione CM, Phillips RS, Lawrence MG, et al. Improved visual function and attenuation of declines in health-related quality of life after cataract extraction. Arch Ophthalmol. 1994;112:1419-1425.
ABSTRACT
38. Alonso J, Espallargues M, Andersen TF, et al. International applicability of the VF-14: an index of visual function in patients with cataracts. Ophthalmology. 1997;104:799-807.
ISI
| PUBMED
39. Cassard SD, Patrick DL, Damiano AM, et al. Reproducibility and responsiveness of the VF-14: an index of functional impairment in patients with cataracts. Arch Ophthalmol. 1995;113:1508-1513.
ABSTRACT
40. Tielsch JM, Steinberg EP, Cassard SD, et al. Preoperative functional expectations and postoperative outcomes among patients undergoing first eye cataract surgery. Arch Ophthalmol. 1995;113:1312-1318.
ABSTRACT
41. Lundstrom M, Barry P, Leite E, Seward H, et al. 1998 European Cataract Outcome Study: report from the European Cataract Outcome Study Group. J Cataract Refract Surg. 2001;27:1176-1184.
FULL TEXT
|
ISI
| PUBMED
42. Chang-Godinich A, Our RJ, Koch DD. Functional improvement after phacoemulsification cataract surgery. J Cataract Refract Surg. 1999;25:1226-1231.
FULL TEXT
|
ISI
| PUBMED
43. Capodaglio EM. Comparison between the CR10 Borg's scale and the VAS (visual analogue scale) during an arm-cranking exercise. J Occup Rehabil. 2001;11:69-74.
FULL TEXT
|
ISI
| PUBMED
44. Bernth-Petersen P. Visual functioning in cataract patients: methods of measuring and results. Acta Ophthalmol (Copenh). 1981;59:198-205.
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