What impacts patient satisfaction with reconstructive pelvic surgery?

Abstract

Related articles, pages 179 and 181. Related articles, pages 179 and 181. Patient satisfaction is an increasingly important outcome measure, as reconstructive pelvic surgery and health care in general evolve and strive for a more patient-centered model. Over the last few decades, the definition of success after surgery for pelvic floor disorders evolved from traditional objective outcome measures to outcomes that incorporate patient expectations, satisfaction, and quality of life. Simultaneously, health care changes linking patient satisfaction to quality measures, which affect physician and hospital reimbursement, further motivate advances to better understand key factors in patient satisfaction. It is imperative to differentiate between satisfaction with the outcome of care and satisfaction with the process of care to ultimately understand how they impact one another.1Donabedian A. The quality of care. How can it be assessed?.JAMA. 1988; 260: 1743-1748Crossref PubMed Scopus (4487) Google Scholar Process of care, including the delivery of and access to care, likely impact patients’ satisfaction and their perceptions of their treatment outcomes; thus, each factor that impacts process of care needs further elucidation. Mounting peer-reviewed literature in urogynecology as well as other surgical fields supports that satisfaction is associated with preoperative patient expectations, which are likewise influenced by patient knowledge and understanding. Studies allowing patients to self-select goals for surgery demonstrate strong correlations between goal achievement, satisfaction, and condition-specific improvements in quality-of-life measures.2Elkadry E.A. Kenton K.S. FitzGerald M.P. Shott S. Brubaker L. Patient-selected goals: a new perspective on surgical outcome.Am J Obstet Gynecol. 2003; 189: 1551-1558Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 3Hullfish K.L. Bovbjerg V.E. Steers W.D. Patient-centered goals for pelvic floor dysfunction surgery: long-term follow-up.Am J Obstet Gynecol. 2004; 191: 201-205Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Similarly, there is mounting evidence that patients who feel prepared prior to prolapse and incontinence surgery are more likely to be satisfied with their surgical outcome regardless of anatomic or functional success.4Kenton K. Pham T. Mueller E. Brubaker L. Patient preparedness: an important predictor of surgical outcome.Am J Obstet Gynecol. 2007; 197: 654.e1-654.e6Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 5Brubaker L. Litman H.J. Rickey L. et al.Surgical preparation: are patients “ready” for stress urinary incontinence surgery?.Int Urogynecol J. 2014; 25: 41-46Crossref PubMed Scopus (15) Google Scholar Two important articles published this month by Greene et al6Greene K.A. Wyman A.M. Scott L.A. et al.Evaluation of patient preparedness for surgery: a randomized controlled trial.Am J Obstet Gynecol. 2017; 217: 179.e1-179.e7Abstract Full Text Full Text PDF Scopus (19) Google Scholar and Hallock et al7Hallock J.L. Rios R. Handa V.L. Patient satisfaction and informed consent for surgery.Am J Obstet Gynecol. 2017; 217: 181.e1-181.e7Abstract Full Text Full Text PDF Scopus (42) Google Scholar demonstrate the priority reconstructive pelvic surgeons place on improving patient satisfaction with the surgical consent process. Hallock et al7Hallock J.L. Rios R. Handa V.L. Patient satisfaction and informed consent for surgery.Am J Obstet Gynecol. 2017; 217: 181.e1-181.e7Abstract Full Text Full Text PDF Scopus (42) Google Scholar showed a woman’s preoperative satisfaction with her decision to undergo pelvic reconstructive surgery was associated with her knowledge after the informed consent discussion. Study participants all elected to undergo surgery; therefore, not surprisingly, nearly all the women were highly satisfied with their surgical decision. However, women who were slightly less satisfied with their preoperative decision to undergo surgery had poorer comprehension about the surgery, which may reflect poor understanding of the informed consent discussion. In particular, women less satisfied with their decision to undergo surgery scored lower on questions related to procedural risks or complications as well as surgical success rates. These data are consistent with prior reports that postoperative dissatisfaction 3 months and 1 year after reconstructive pelvic surgery was associated with feeling unprepared for surgery and perceived complications.2Elkadry E.A. Kenton K.S. FitzGerald M.P. Shott S. Brubaker L. Patient-selected goals: a new perspective on surgical outcome.Am J Obstet Gynecol. 2003; 189: 1551-1558Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 8Mahajan S.T. Elkadry E.A. Kenton K.S. 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: 722-728Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Similarly, patients who experience postoperative complications are less likely to achieve their self-selected goals.3Hullfish K.L. Bovbjerg V.E. Steers W.D. Patient-centered goals for pelvic floor dysfunction surgery: long-term follow-up.Am J Obstet Gynecol. 2004; 191: 201-205Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 9Hullfish K.L. Bovbjerg V.E. Gibson J. Steers W.D. Patient-centered goals for pelvic floor dysfunction surgery: what is success, and is it achieved?.Am J Obstet Gynecol. 2002; 187: 88-92Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Our team prospectively studied women’s perception of their preparedness for surgery and a variety of patient and physician-centered surgical outcomes.4Kenton K. Pham T. Mueller E. Brubaker L. Patient preparedness: an important predictor of surgical outcome.Am J Obstet Gynecol. 2007; 197: 654.e1-654.e6Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Women who felt prepared for reconstructive pelvic surgery had better comprehension after informed consent, which was also associated with better symptom improvement, satisfaction, and quality of life following surgery; however, objective outcome measures were not associated with satisfaction. Similar themes were found in a multicenter trial of women undergoing stress incontinence surgery.5Brubaker L. Litman H.J. Rickey L. et al.Surgical preparation: are patients “ready” for stress urinary incontinence surgery?.Int Urogynecol J. 2014; 25: 41-46Crossref PubMed Scopus (15) Google Scholar Only half of women in this study felt prepared for surgery and higher preoperative preparedness scores were associated with greater postoperative satisfaction, although surgical success rates did not differ. Perhaps preparedness and satisfaction with the decision to proceed with surgery are measuring similar patient care and process care attributes. Both preparedness and satisfaction before and after reconstructive surgery are associated with a patient’s knowledge and comprehension about surgery. The interaction between the physician and patient before surgery seems to improve patients’ preparedness and satisfaction with the decision to have surgery as well as satisfaction with the outcome of surgery. Greene et al6Greene K.A. Wyman A.M. Scott L.A. et al.Evaluation of patient preparedness for surgery: a randomized controlled trial.Am J Obstet Gynecol. 2017; 217: 179.e1-179.e7Abstract Full Text Full Text PDF Scopus (19) Google Scholar sought to determine if the addition of a patient education video to the preoperative consultation and informed consent process improved how well prepared patients felt for reconstructive pelvic surgery. The addition of the video to the informed consent discussion did not improve patient’s preparedness for surgery, although the patient’s perception of time that the health care team spent with her was associated with feeling prepared for surgery. Interestingly, the actual time the physician spent with the patient was not related to her feelings of preparedness. Patient’s perceptions of the risks and complications of surgery may play a more important role in perioperative satisfaction than anticipated. Studies consistently report lower satisfaction in women, who do not fully understand the risks and complications of surgery or who experience adverse events or complications. Given emerging data regarding knowledge, expectations, and satisfaction, a potential area for impact may be more directed discussions of procedural risks and complications. Women undergoing midurethral sling surgery are more likely to recall alternatives and benefits of the procedure than they are risks and complications,10McFadden B.L. Constantine M.L. Hammil S.L. et al.Patient recall 6 weeks after surgical consent for midurethral sling using mesh.Int Urogynecol J. 2013; 24: 2099-2104Crossref PubMed Scopus (18) Google Scholar although surgeons are more likely to discuss surgical risks than alternatives and benefits.11Abed H. Rogers R. Helitzer D. Warner T.D. Informed consent in gynecologic surgery.Am J Obstet Gynecol. 2007; 197: 674.e1-674.e5Abstract Full Text Full Text PDF Scopus (18) Google Scholar Investigators in this study, similar to Greene et al,6Greene K.A. Wyman A.M. Scott L.A. et al.Evaluation of patient preparedness for surgery: a randomized controlled trial.Am J Obstet Gynecol. 2017; 217: 179.e1-179.e7Abstract Full Text Full Text PDF Scopus (19) Google Scholar found that length of time of the informed consent process impacted immediate recollection of risks and complications, but the association was no longer present 6 weeks after surgery. Future studies focusing on better methods to enhance patient understanding and retention of surgical risks may have important impact on surgical satisfaction. Other influences on women’s satisfaction and preparedness for reconstructive surgery may be more related to lifestyle than complete resolution of pelvic floor symptoms. One study investigating patient-selected goals for reconstructive pelvic surgery found that 44% of goals women listed were related to activity and 50% were related to lifestyle.2Elkadry E.A. Kenton K.S. FitzGerald M.P. Shott S. Brubaker L. Patient-selected goals: a new perspective on surgical outcome.Am J Obstet Gynecol. 2003; 189: 1551-1558Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar Women who listed a higher number of goals for surgery reported more specific lifestyle expectations from surgery; in contrast, women listing only 1 or 2 goals were simply focused on correcting the pelvic floor disorder. Goal achievement was highly correlated with a return to normal activities and lifestyle, while prolonged return to normal activities was associated with decreased goal achievement and satisfaction. A recently published randomized trial comparing traditional postoperative activity and lifestyle restrictions to liberal resumption of activities demonstrated high satisfaction in both groups; however, women allowed to liberally resume their activities reported fewer bothersome pelvic floor symptoms.12Mueller M.G. Lewicky-Gaupp C. Collins S.A. Abernethy M.G. Alverdy A. Kenton K. Activity restriction recommendations and outcomes after reconstructive pelvic surgery: a randomized controlled trial.Obstet Gynecol. 2017; 129: 608-614Crossref PubMed Scopus (20) Google Scholar Two key factors consistently influencing women’s satisfaction with reconstructive surgery are expectations for their care and preparedness or knowledge regarding the procedure. Patient education regarding perioperative details of the surgery are essential in helping patients set realistic goals and improving their knowledge and comprehension about the procedure. These 2 factors arguably impact patient-reported outcomes and perception of improvement more than any objective measures of surgical success. The studies by Hallock et al7Hallock J.L. Rios R. Handa V.L. Patient satisfaction and informed consent for surgery.Am J Obstet Gynecol. 2017; 217: 181.e1-181.e7Abstract Full Text Full Text PDF Scopus (42) Google Scholar and Greene et al6Greene K.A. Wyman A.M. Scott L.A. et al.Evaluation of patient preparedness for surgery: a randomized controlled trial.Am J Obstet Gynecol. 2017; 217: 179.e1-179.e7Abstract Full Text Full Text PDF Scopus (19) Google Scholar are consistent with prior work and accentuate that the complexities of the surgical consent process go beyond physician perceptions of information transfer or simply time spent in informed consent discussions. Given the clear impact of the process of care during the surgical consent on patient knowledge, preparedness, and satisfaction with the outcome of care, we must identify better ways to help patients set realistic expectations and comprehend alternatives, benefits, and perhaps most importantly, risks and potential complications of surgery. Evaluation of patient preparedness for surgery: a randomized controlled trialAmerican Journal of Obstetrics & GynecologyVol. 217Issue 2PreviewPatient preparedness for pelvic reconstructive surgery has important implications for patient satisfaction and the perception of improvement after surgery. The ideal method in which to optimally prepare patients for surgery has not been determined. Full-Text PDF Patient satisfaction and informed consent for surgeryAmerican Journal of Obstetrics & GynecologyVol. 217Issue 2PreviewInformed consent is a process that necessitates time and effort. Underlying this investment is the belief that informing patients about the surgery promotes patient satisfaction with the decision for surgery and potentially satisfaction more broadly. Full-Text PDF