Patient Expectations Of Outcomes Research Articles

Poster 184: Demographics and Outcomes of Shoulder Instability in Individuals with Elevated Body Mass Index

Objectives: Traumatic shoulder dislocations in the adolescent, active adult, and elderly have been well studied. However, to our knowledge, no specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The objective of this study is to describe shoulder dislocations in patients with body mass index (BMI) greater than 40. Methods: A retrospective chart review was performed to identify patients 18 years of age and older with a BMI greater than or equal to 40 who presented with a shoulder dislocation within a single institution from 2000-2020 were included in this study. Patients who had a BMI of less than 40, sustained a periprosthetic shoulder dislocation, and patients who were pregnant were excluded from this study. Dislocation pattern, associated injuries, treatment modalities, and associated complications were recorded. Complications were defined to include recurrent instability as demonstrated by a single recurrent dislocation event, infection, arthrofibrosis, and associated neurovascular injury. Results: Seventy-seven patients were included in our study. Fifty-two patients (67.5%) were female. Average age was 47.95 ± 2.06 (range 18-81), with average BMI of 45.01 ± 5.67 (range 40-78). Mean follow up for our patient cohort was 411.5 days (1.13 years). Sixty-five dislocations (84%) were due to a ground level fall whereas 8 (10%) were due to assault and 4 (5%) were due to a motor vehicle collision (MVC) (p<0.01). There was a significant increase in the number of patients with BMI greater than 40 presenting per year (r2 = - 0.831, p < 0.01) over the past 20 years. In addition, there was also a significant increase in the average BMI per year in this population (r2 = 0.504, p=0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode, with average time to recurrent dislocation of 449 days (1.23 years). Hill-Sachs lesions were the most common associated injury (p=0.03). Bankart lesions were the only associated injury that were found to be associated with an elevated BMI (p = 0.04), Nine patients (11.7%) sustained an associated neurologic injury which was found to have no association with BMI. There were 56 patients (72.7%) who were managed non-operatively and 21 patients (27.3%) who underwent surgical intervention. One patient failed nonoperative management and arthroscopic stabilization, going on to require shoulder arthrodesis and biceps tenodesis. They subsequently developed a post-operative infection necessitating revision arthrodesis. Conclusions: Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations. These injuries most commonly happen due to low energy mechanisms and can be associated with Bankart lesions and associated neurologic injuries. There was a recurrent dislocation rate of 19.5%, which is consistent with this age cohort. As the current trend continues it will become increasingly important to better understand these injuries. Morbidly obese patients may incur higher health care costs and resource expenditure to treat such injuries. In addition, appropriate patient education and outcome expectations for nonoperative and operative treatment should be provided given the high risk of recurrent dislocations in this patient population.

Poster 235: The Role of Symptom Duration in Shaping Outcome Expectations of Patients Initiating Nonoperative Treatment for Meniscal Tear

Objectives: Nonoperative treatment represents a safe, guideline-based approach for meniscal injuries, but it is unclear why or how it works. It is often assumed that nonoperative treatments (e.g., physical therapy) exerts their effects (e.g., symptom relief) via technical procedures (e.g., exercise regimen) but a variety of nonspecific factors (e.g., expectations for treatment and its credibility) commonly part of any treatment (e.g., physical therapy, surgery, pharmacotherapy, behavior therapy, etc.) also influence outcomes. In general, patients who believe a treatment is believable, convincing or logical (credibility) and will be useful for relieving the symptoms for which they seek treatment (outcome expectancy) are more likely to achieve clinically meaningful change than patients with negative expectancies. Patients with low treatment credibility and outcome expectancies not only may be less likely to achieve treatment goals but may also be at greater risk for dropout. Despite evidence supporting their role in pharmacotherapy and behavior therapy, little research has been carried out in understanding the role of treatment credibility and expectancies in shaping successful treatment of rehabilitative treatments for meniscal tears. Utilizing baseline data collected from the Treatment of Meniscal Tears in Osteoarthritis trial we sought to assess treatment credibility and treatment expectancies for improvement of knee symptoms and their clinical and sociodemographic correlates. Given the strong influences of cognitive processes on pain as it persists, our a priori hypothesis was that expectations for symptom improvement would be greater for patients with shorter duration of knee symptoms than those with persistent knee symptoms. Methods: Participants included 126 patients (58 years old (range: 45-75), 51% women, 91% white) who rated credibility of treatment to which they were assigned and expectations for symptom improvement using a modified version of the Credibility Expectancy Questionnaire (CEQ-Meniscus Treatment) based on a psychometrically validated measure two weeks post randomization. Ratings were obtained after rationale for treatment was provided but before the full scope of therapy was implemented so as not to contaminate them by treatment response. Credibility ratings were calculated by taking the mean of the first three items of the CEQ to create an overall credibility rating (9-point scale). We adopted the practice of measuring expectancy by using the CEQ-MT that asks patients to rate, on a 0 to 100% scale (in 10-point increments), “By the end of treatment, how much improvement in knee symptoms do you think will occur?” We also examined expectancy items from the Musculoskeletal Outcomes Data Evaluation and Management Scale (MODEMS) that assess pretreatment expectations for relief of knee symptoms and their impact on activities of living (e.g., housework, sleep). Each item had a possible range of 1 (not likely) to 5 (extremely likely). Overall MODEMS symptom expectancy scores were calculated by taking the mean of the first 5 items. Results: Ninety-three percent of the participants completed the survey. On the CEQ-MT, average treatment credibility (Mean = 6.5) and expectancy ratings (Mean = 70%) were high. Similarly, the MODEMS expectancies were high, on average (Mean = 4.0). Expectancies for improvement and the extent to which treatment was deemed credible moderately correlated with each other ( r range 0.30 - 0.52, p<.05). Credibility but not outcome expectancy varied by race, with participants identifying as white reporting higher treatment average credibility scores, 5.2 and 6.5, p=.03, respectively. Credibility scores did not vary by knee pain duration. Patients experiencing knee pain for 0-2 months (i.e., acute) expected, on average, that a 76% improvement would occur by the end of therapy, compared with 64% for patients experiencing pain persisting 3 months and longer (i.e., chronic), p=.002. Similarly, mean MODEMS expectancy scores varied by pain duration, with acute patients reporting stronger expectancies of symptom reduction than their chronic counterparts (4.2 and 3.8, p=.002). Conclusions: To our knowledge, this is the first study that has sought to assess systematically baseline levels of perceived treatment credibility and expectations for improvement in a cohort of patient undergoing nonoperative therapy for meniscus tears. Our primary findings are treatment credibility varied by race and that treatment outcome expectancies differed significantly by pain duration (acute vs chronic). Understanding beliefs patients have about treatment is a clinically relevant research focus because they are among the most powerful “common factors” (i.e., those that are not specific to any one treatment but are shared across all) that can influence treatment outcomes above and beyond technical components of a therapy. Their role in contributing to the management of meniscus tear is unknown. Data from this study suggest that common factors such as treatment expectancy may be particularly operative in patients whose knee symptoms following meniscus injuries persists beyond the acute phase.

Participant factors as correlates of patients’ psychotherapy outcome expectation: A meta-analytic and box-count review

ABSTRACT Objective More positive pre- or early therapy patient outcome expectation (OE) has consistently correlated with better treatment outcomes. Thus, it is important to identify factors that contribute to patients’ OE, which can inform therapist responsivity to such risk or facilitative markers. With growing research on OE correlates—centered primarily on patient characteristics/treatment factors and, to a lesser extent, therapist factors—a comprehensive synthesis is warranted to elucidate replicated and mixed associations and stimulate further research. Accordingly, we set a pragmatic cutoff of k ≥ 5 for meaningful empirical aggregation of participant factor-OE associations; otherwise, we conducted box counts. Method We searched for articles published through March 2022 that included a clinical sample, a measure of patient’s pre- or early treatment OE, and an explicit test of the factor-OE association. Results Patient problem severity, problem chronicity, education, age, and quality of life were meta-analyzed. Greater severity correlated with lower/less optimistic OE (r = −0.13, p < .001) and higher QOL correlated with higher/more optimistic OE (r = 0.18, p < .001). Box counts revealed that few variables had consistent associations with OE. Conclusions Some factors can help forecast patient OE, though additional research is needed to enhance confidence and clinical meaning.

Emotional, cognitive, and physical well-being during the wait for breast biopsy results

The experience of waiting for breast biopsy results can cause clinically significant levels of psychological distress. Objective This study is a replication and extension of previous work examining the well-being of patients at a breast biopsy appointment. Expanding on a previous study, we aim to identify predictors of well-being following the appointment (i.e. waiting for results). Design In this longitudinal study, female patients (N = 197) were surveyed at their breast biopsy appointments and then completed daily surveys assessing distress and coping during the week-long wait for results. Main Outcome Measures Surveys asked about patient characteristics, subjective health, cancer history, support availability, outcome expectations, and distress. Results/Conclusions Consistent with the previous study, health history and demographic factors were largely unassociated with distress, this time while waiting for biopsy results. Latina ethnicity emerged one of the few predictors of coping, pointing to opportunities for differential clinical interventions that take cultural factors into account. Finally, anxiety was highest at the beginning and end of the wait for biopsy results, suggesting that interventions may be most effective following a breast biopsy and the days prior to learning one’s result.

A Systematic Review of Personalized Health Applications through Human-Computer Interactions (HCI) on Cardiovascular Health Optimization.

Introduction: Currently, the deployment of human–computer interactive technologies to provide personalized care has grown and immensely taken shape in most healthcare settings. With the increasing growth of the internet and technology, personalized health interventions including smartphones, associated apps, and other interventions demonstrate prowess in various health fields, including cardiovascular management. This systematic review thus examines the effectiveness of various human–computer interactions technologies through telehealth (mainly eHealth) towards optimizing the outcomes in cardiovascular treatment. Methods: A comprehensive search of MEDLINE, EMBASE, and CINAHL databases using key terms was conducted from 2000 to November 2021 to identify suitable studies that explored the use of human–computer interaction technologies to provide a personalized care approach to facilitate bolstered outcomes for cardiovascular patients, including the elderly. The included studies were assessed for quality and risk of bias, and the authors undertook a data extraction task. Results: Ten studies describing the use of a mix of personalized health app (mHealth) interventions were identified and included in the study. Among the included studies, nine of them were randomized trials. All of the studies demonstrated the effectiveness of various personalized health interventions in maximizing the benefits of cardiovascular disease treatment. Conclusions: Personalized health application interventions through precision medicine has great potential to boost cardiovascular disease management outcomes, including rehabilitation. Fundamentally, since each intervention’s focus might differ based on the disease and outcome preference, it is recommended that more research be done to tailor the interventions to specific disease and patient outcome expectations.

The Role of Patient Recovery Expectations in the Outcomes of Physical Therapist Intervention: A Systematic Review.

The purpose of this study was to determine the association between baseline patient recovery expectations and outcomes following physical therapy care. PubMed, CINAHL Complete, PEDro, SPORTDiscus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PsycINFO were searched from inception to February 2021. Concepts represented in the search included physical therapy, patient expectations, patient outcomes, and their relevant synonyms. Two reviewers independently screened studies of article abstracts and full texts. Eligibility criteria included English language studies that evaluated adults seeking physical therapist intervention for any health condition where both patient outcome (recovery) expectations and functional or other outcome measures were reported. Methodologic standards were assessed using the Critical Appraisal Skills Program criteria. Data were extracted using a custom template for this review with planned descriptive reporting of results. Vote counting was used to measure reported outcomes. Twenty-one studies were included in this review, representing 4879 individuals. Studies were most commonly prospective cohort studies or secondary analyses of controlled trials. Varied expectation, outcome, and statistical measures that generally link patient recovery expectations with self-reported outcomes in musculoskeletal practice were used. Patient recovery expectations are commonly associated with patient outcomes in musculoskeletal physical therapy. Evidence supports measuring baseline patient expectations as part of a holistic examination process.

Therapist-level moderation of within- and between-therapist process-outcome associations.

Although higher quality patient-therapist alliance and more positive patient outcome expectation (OE) consistently predict symptomatic/functional improvement in psychotherapy, most research has failed to capture the nuance in these process-outcome relations by parsing them into within-therapist (i.e., differences between patients treated by the same therapist) and between-therapist (i.e., differences between therapists' average process/outcome ratings across all patients in their caseloads) components. Moreover, the few studies that have done so have produced mixed results, suggesting the possibility of systematic variability in these associations (i.e., moderators). One potential source of such variability could be providers themselves; that is, different therapists could use these processes to differing therapeutic benefit. This study tested the alliance- and OE-outcome associations at both the within- and between-therapist levels and explored therapist-level moderators of them. Data derived from 212 adult outpatients treated naturalistically by 42 psychotherapists as part of a randomized trial that compared different case-assignment methods. Patients completed measures of alliance, OE, and outcome repeatedly throughout treatment. Therapist characteristics were assessed at baseline. Multilevel structural equation models revealed that, at the between-therapist level, only higher alliance quality, but not more optimistic OE, was associated with greater caseload-level improvement. At the within-therapist level, only more optimistic OE, but not higher alliance quality, was associated with patient improvement. Finally, therapists' self-perceived alliance-fostering effectiveness and cognitive-behavioral orientation moderated the within- and between-therapist alliance-outcome associations, respectively. Results indicate that different therapists use common treatment processes to differing therapeutic benefit, which can inform more personalized clinical practices and trainings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychosocial factors and lack of asthma knowledge undermine child and adolescent adherence to inhaled corticosteroid

Objective: This study aimed to evaluate inhaled corticosteroid (ICS) adherence and identify factors associated with nonadherence in pediatric asthma patients. Methods: A total of 134 patients aged 8–18 years old were included. At the first visit, patient adherence, asthma knowledge, and outcome expectation data were collected and recorded. Depression, anxiety, and self-esteem were assessed using psychiatric questionnaires. After providing asthma education, reevaluation of adherence and asthma control was performed at one 3- to 6-month follow-up visit. Results: The mean ICS adherence was 75.9 ± 27.5%. Fifty-seven patients (42.5%) were defined as having poor adherence (<75%). “Intentional” and “hectic lifestyle and forgetfulness” were the main reasons for missing ICS doses in mid-late adolescents and children, respectively. Asthma knowledge generally improved with age. Overall, 89% and 67.7% of patients could define symptoms and triggers of asthma, respectively; however, less than 25% understood how asthma affected their body and the chronic nature of asthma. Patients with ICS adherence <75% had unfavorable expectations from asthma treatment (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01–1.10), and a higher proportion of inhaled short-acting beta-agonist use before exercise (OR: 4.12, 95% CI: 1.27–13.36). Depression and anxiety were frequently found (27.5%) and 23.3%, respectively; p > 0.05). Significant improvement in ICS adherence (p = 0.02) and Asthma Control Test scores (p = 0.02) were observed at the follow-up visit. Conclusions: Patient outcome expectations could be predictors of ICS adherence. Patient education regarding the mechanism and nature of asthma should be considered as an intervention for improving pediatric patient adherence. Psychological evaluation is warranted in pediatric patients with asthma.

PRE-OPERATIVE EXPECTATIONS FOR RETURN TO SPORTS AND OUTCOMES FOLLOWING ACL RECONSTRUCTION: A SURVEY OF ADOLESCENT PATIENTS AND THEIR PARENTS

Background:There is limited data regarding patient and parent expectations regarding return to sport (RTS) and outcomes following anterior cruciate ligament reconstruction (ACLR) in adolescent athletes.Purpose:To investigate RTS and outcome expectations of adolescent patients and their parents before ACLR and determine any differences between groups.Methods:For this cross-sectional study, sets of patients (aged 10 to 18 years) and parents were separately asked to complete the same questionnaire relating to knowledge and expectations regarding the patient’s upcoming ACLR. The custom survey consisted of 12 questions and was administered before being seen by a single sports medicine surgeon in the clinical setting of a tertiary care referral center from June 2019 through June 2020. Statistical analysis was performed to compare differences between patient and parent/guardian responses.Results:28 sets of patients (53.6% female) and parents (64.3% female) completed the survey with average ages of 14.5 ± 2.0 years and 45.6 ± 7.0 years, respectively. 75% of families were Caucasian and 85.2% had private insurance. The most common sports played were basketball (25%) and soccer (17.9%). Overall, nearly 68% of consults were for a second opinion. 50% of patients and 82.1% of parents researched or read of ACL injuries and/or surgery prior to the visit. Most patients (46.4%) and parents (51.9%) expected the surgeon to consider full, unrestricted RTS/activities at 9 months. Only 7.1% of patients and 3.7% of parents believed full RTS would occur >12 months. 50% of patients and 67.9% of parents expected RTS at the same level. Both patients (53.6%) and parents (64.3%) believed fear of re-injury was the most common reason for not returning to sport or returning at a decreased level. There were no statistically significant differences in RTS expectations between patients and parents (p>0.05). Most patients (38.5%) believed the risk of graft rupture in adolescent athletes was 5%, whereas most parents (37%) believed the risk to be at 25%, but the difference was not statistically significant (p>0.05). Both patients and parents believed the risk of graft rupture was highest within the first 6 months (77.8% vs. 50%, respectively). More parents felt the risk of graft rupture was highest within the first year (39.3% vs. 22.2%), but the difference was not statistically significant (p>0.05).Conclusion:Adolescent patients and their parents had similar knowledge and expectations regarding RTS and outcomes following ACLR. Further study is needed to better understand factors affecting those expectations.

Association between therapist attunement to patient outcome expectation and worry reduction in two therapies for generalized anxiety disorder.

Patients' higher psychotherapy outcome expectation (OE) correlates with improvement. Thus, it seems important that therapists attune to this belief, both in the moment and over time, to capitalize on its value when higher or respond to its potential risk when lower. Conceptually, attunement can have different guises, including the extent to which therapists (a) accurately estimate their patients' momentary OE level (low directional discrepancy), (b) become more accurate in estimating OE over time (convergence), (c) accurately track shifts in their patients' OE (temporal congruence), and (d) become more temporally congruent over time (alignment). To date, though, little is known empirically about therapist attunement to patient OE. Thus, we examined the presence of attunement indices and their relation to posttreatment outcome. Data derived from a randomized trial that compared cognitive-behavioral therapy (CBT; n = 43) to CBT plus motivational interviewing (n = 42) for patients with generalized anxiety disorder. After each session, patients rated their OE, and therapists estimated their patients' OE. Patients rated worry at baseline and posttreatment. Dyadic multilevel modeling revealed that across both treatments, therapists were directionally discrepant in that they underestimated patients' OE (p < .001), which did not change over time (no average convergence/divergence pattern; p = .43). Additionally, therapists exhibited temporal congruence with patients' OE (p < .001) and became more aligned with this rating over time (p = .008). Only greater OE convergence, when it occurred, predicted lower worry (p = .04). A therapist's increasingly accurate empathy about their patients' OE may be therapeutic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Indirect effect of patient outcome expectation on improvement through alliance quality: A meta-analysis

Objective: A meta-analysis revealed a positive correlation between patients’ optimistic baseline, or early treatment, outcome expectation (OE) and posttreatment improvement (Constantino, Vîslă, et al., [2018]. A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473–485. https://doi.org/10.1037/pst0000169). However, little is known about mechanisms through which OE operates. Increasingly, several individual studies have pointed to higher therapeutic alliance quality as a promising mediator (candidate mechanism) of the positive OE-improvement link. In this study, we conducted the first meta-analysis of this indirect effect, hypothesizing that alliance would partially mediate the OE-outcome link. Method: We included published articles involving a clinical sample; therapist-led treatment of at least 3 sessions; pre- or early treatment patient OE measures; during-treatment patient-rated alliance measures; posttreatment outcome measures; and statistical tests of mediation. This meta-analysis included 10 independent samples and over 1,000 patients. Results: As expected, better alliance quality partially mediated the association between more optimistic OE and improvement; that is, although both were significant, a multivariate analysis revealed that the direct effect was significantly lower than the total effect (standardized difference = −.12, p < .001, 95% CI [−.20, −.05]). Publication bias was low, as was heterogeneity except for the alliance-outcome path. Conclusions: Better alliance may be one process that helps transmit the therapeutic influence of early patient OE.

Supplemental Material for Association Between Therapist Attunement to Patient Outcome Expectation and Worry Reduction in Two Therapies for Generalized Anxiety Disorder

Supplemental Material for Association Between Therapist Attunement to Patient Outcome Expectation and Worry Reduction in Two Therapies for Generalized Anxiety Disorder

A Population-based Study of Immunotherapy-related Toxicities in Lung Cancer

BackgroundPopulation-level data regarding incidences of immune-related adverse events (irAEs) are lacking. This study evaluated the frequencies of irAEs among patients with non–small-cell lung cancer (NSCLC) who received immune checkpoint inhibitors. Patients and MethodsAdministrative claims data from a large United States commercial insurance database (OptumLabs Data Warehouse) were used to retrospectively identify patients with NSCLC between January 1, 2015 and December 31, 2017 who received a programmed death-ligand 1/programmed cell death protein-1 (PD(L)-1) inhibitor. Cumulative risks for irAEs were estimated at 1, 3, 6, 9, and 12 months after initiation of a PD-(L)1 inhibitor. Additionally, associations between patient characteristics and frequency of irAEs were investigated utilizing multivariate logistic modeling. ResultsThe risk of developing any irAE was 52.5% (95% confidence interval, 49.9%-55.2%) after 12 months in 3164 patients with NSCLC who initiated a PD-(L)1 inhibitor (median age, 69.0 years; 1763 [55.7%] males; 1401 [44.3%] females). Cumulative risks of irAEs increased over time: pneumonitis was recorded in 2.5% of patients 1 month after initiation of treatment, and increased to 14.3% after 9 months. Risks of hypophysitis and pericarditis were 3.6% and 1.7% at 9 months, respectively. Patients who received PD-(L)1 inhibitors in the first line had lower frequencies of irAEs (hazard ratio, 0.77; 95% confidence interval, 0.67-0.87). ConclusionOur findings suggest that the frequencies of some irAEs may be higher than the rates reported in the pivotal trials that led to United States Food and Drug Administration approvals for PD-(L)1 inhibitors. These real-world data refine provider and patient expectations for outcomes in a broader population beyond what is observed in clinical trials.

Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients.

End-stage osteoarthritis is commonly treated with joint replacement. Despite high clinical success rates, up to 28% of patients are dissatisfied with the outcome.This best-evidence synthesis aimed to review studies with different forms of study design and methodology that examined the relationship between (fulfilment of) outcome expectations of hip and knee patients and satisfaction with outcome.A literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane, and Google Scholar to identify studies conducted up to November 2017. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale.In this best-evidence synthesis systematic review, the following main results could be seen. In only half of all studies were preoperative expectations associated with level of satisfaction, while in almost all studies (93%), fulfilment of expectations was related to satisfaction. The effect of met expectations did not differ between hip and knee patients or study design.Fulfilment of expectations seems to be consistently associated with patient satisfaction with outcome. Emphasis in future research must be placed on the operationalization and measurement of expectations and satisfaction to determine the (strength of the) influence of these different forms of assessment on the (existence of the) relationship.Cite this article: EFORT Open Rev 2020;5:226-240. DOI: 10.1302/2058-5241.5.190015

A Comparison of Patient and Surgeon Expectations of Spine Surgical Outcomes.

Study Design:Ambispective cohort study.Objective:Limited data exists comparing surgeon and patient expectations of outcome following spine surgery. The objective of this study was to elicit whether any differences exist between patient and surgeon expectations for common spine surgeries.Methods:Ten common age-appropriate clinical scenarios were generated and sent to Canadian spine surgeons to determine surgeon expectations for standard spine surgeries. Patients in the Canadian Spine Outcomes and Research Network (CSORN) registry matching the clinical scenarios were identified. Aggregated patient expectations were compared with surgeon responses for each scenario. A χ2 analysis was then completed to determine discrepancies between surgeon and patient expectations for each scenario.Results:A total of 51 Canadian spine surgeons completed the survey on surgical expectations. A total of 919 patients from multiple centers were identified within the CSORN database that matched the clinical scenarios. Our results demonstrated that patients tend to be more optimistic about the expected outcomes of surgery compared with the treating surgeon. The majority of patients in all clinical scenarios anticipated improvement in back or neck pain after surgery, which differed from surgeon expectations. Results also highlighted the effect of patient age on both patient and surgeon expectations. Discrepancies between patient and surgeon expectations were higher for older patients.Conclusion:We present data on patient and surgeon expectations for spine surgeries and show that differences exist particularly concerning the improvement of neck or back pain. Patient age plays a role in the agreement between the treating physicians and patients in regard to surgical expectations. The reasons for the discrepancies remain unclear.

Dyadic, longitudinal associations among outcome expectation and alliance, and their indirect effects on patient outcome.

Research indicates that patient outcome expectation (OE) correlates with improvement, and that this association may be mediated by better patient-therapist alliances. However, despite OE and alliance being dyadic and dynamic constructs, most research on these direct and indirect associations has assessed these variables from only one dyad member's perspective and at single time points. Addressing these gaps, we used a longitudinal actor-partner interdependence model to first examine OE-alliance associations. Namely, we assessed "actor" effects (relation between each member's OE at 1 session and his or her own next session alliance) and "partner" effects (relation between each member's partner's OE at 1 session and his or her own next session alliance). Second, we tested whether significant actor or partner effects of OE on alliance translated into better patient outcomes (indirect effects). Analyses were conducted at within- and between-dyad levels. Data derived from a generalized anxiety disorder trial in which 85 patients received 15 sessions of either cognitive-behavioral therapy (CBT) or CBT integrated with motivational interviewing. After every session, patients and therapists rated OE and alliance, and patients rated their worry. At the within-dyad level, there were OE-alliance actor effects for both patients and therapists. There was also a within-dyad partner effect; when patients had greater OE at one session their therapists reported better next-session alliances. Finally, all within-dyad effects in turn related to lower subsequent worry. Results reveal ways in which session-by-session fluctuations in both patient and therapist OE translate into better outcomes through their influence on alliance quality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Keratitis following laser refractive surgery: Clinical spectrum, prevention and management.

Laser refractive surgery (LRS) is one of the most demanding areas of ophthalmic surgery and high level of precision is required to meet outcome expectations of patients. Post-operative recovery is of vital importance. Keratitis occurring after LRS can delay visual recovery. Both surface ablations [Photorefractive keratectomy (PRK)] as well as flap procedures [Laser in-situ keratomileusis (LASIK)/Small incision lenticule extraction] are prone to this complication. Reported incidence of post-LRS infectious keratitis is between 0% and 1.5%. The rate of infections after PRK seems to be higher than that after LASIK. Staphylococci, streptococci, and mycobacteria are the common etiological organisms. About 50–60% of patients present within the first week of surgery. Of the non-infectious keratitis, diffuse lamellar keratitis (DLK) is the most common with reported rates between 0.4% and 4.38%. The incidence of DLK seems to be higher with femtosecond LASIK than with microkeratome LASIK. A lot of stress is laid on prevention of this complication through proper case selection, asepsis, and use of improved protocols. Once keratitis develops, the right approach can help resolve this condition quickly. In cases of suspected microbial keratitis, laboratory identification of the organism is important. Most lesions resolve with medical management alone. Interface irrigation, flap amputation, collagen cross-linking and therapeutic penetrating keratoplasty (TPK) are reserved for severe/non-resolving cases. About 50–75% of all infectious keratitis cases post LRS resolve with a final vision of 20/40 or greater. Improved awareness, early diagnosis, and appropriate intervention can help limit the damage to cornea and preserve vision.

Patients’ expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUNDUnderstanding patient expectations is a critical component of patient-centered care; however, little is known about which expectation(s) are most important to patients as they relate to their sense of postoperative success. PURPOSETo investigate patient's preoperative expectations of change in symptoms, function, and well-being resulting from surgical intervention and to examine the associations between sociodemographic, lifestyle, health status, and clinical characteristics with patient outcome expectations STUDY DESIGNObservational cross-sectional study. SAMPLEPreoperative data from the Canadian Spine Outcomes and Research Network national registry of patients of patients (n=4,333) undergoing surgery for degenerative spinal conditions between 2012 and 2017. OUTCOME MEASURESPatients reported their expectations as a result of the surgery (0 [no change], 1 [somewhat better], 2 [better] or 3 [much better]) for seven items: leg/arm pain, back/neck pain, independence in everyday activities, sporting activities/recreation, general physical capacity, frequency and quality of social contacts, and mental well-being. Patients also reported the single most important change expected. METHODSData on demographic, lifestyles, health status, clinical factors, and reasons for having surgery were also collected. Factor analysis was used to examine the multidimensionality of expectations. Multivariate linear regression was used to examine factors associated with expectations. RESULTSOver 80% of patients reported expectation for improvements (at least somewhat better) in all items with the exception of social contacts (75.8%). Expectations are multidimensional; a two factor structure emerged indicating two expectation dimensions (pain relief and overall functional well-being). Two expectation scores were calculated corresponding to the two dimensions (0–100), with higher scores reflecting higher expectations. The mean±standard deviation pain relief expectation score was 78.5±24.7 and the mean overall functional well-being expectation score was 69.7±24.4. In multivariate analysis, the variables associated with these dimensions either differed or differed in degree of influence. For example, higher pain and disability scores, thoracolumbar location and diagnosis of spondylolisthesis were associated with higher expectations in both dimensions, while longer disease duration was only associated with lower overall functional well-being expectations. The top three most important expected change items were pain (improvement of leg or arm pain (29.1%)/improvement in back/neck pain (26.0%)), improvement in general capacity/function (21.0%), and improvement of independence in everyday activities (15.9%). Rankings of the most important expected change were similar across sociodemographic, lifestyle, health status, and clinical variables examined. CONCLUSIONSOur findings highlight the need to identify and address specific individual expectations as part of the shared decision-making and presurgery education process.

Outcome Expectations of Total Knee Arthroplasty Patients: The Influence of Demographic Factors, Pain, Personality Traits, Physical and Psychological Status.

Unfulfilled preoperative expectations have a strong influence on the outcome after total knee arthroplasty (TKA). More insight into determinants of the level of expectations is useful in identifying patients at risk for having expectations of the treatment result that are too high or too low. This information can be used in optimizing preoperative expectation management. The aim of the current study was to analyze to what extent preoperative outcome expectations of TKA patients are affected by psychological factors, demographic factors, pain, physical function, and general health status. We performed a cross-sectional analysis of 204 patients with symptomatic and radiographic knee osteoarthritis (OA), scheduled for primary TKA. Outcome expectations were measured using the hospital for special surgery knee replacement expectations survey. Independent variables included were age, sex, body mass index, and patient-reported outcome measures for pain, physical function, quality of life, anxiety, depression, catastrophizing, optimism, and pessimism. Multiple linear regression analyses were used to evaluate associations between these variables and preoperative outcome expectations. Female sex, higher age, higher depression score, and duration of complaints > 50 months showed to be significant predictors of lower expectations for the treatment outcome after TKA. Baseline pain and function scores were not related to the level of preoperative expectations. The present study aids in identifying patients at risk for having either too high or too low expectations. This knowledge can be utilized in individualized expectation management interventions.

Immunotherapy-related toxicities: More common than originally reported?

184 Background: Population level data regarding incidence of immune-related adverse events (irAE) is lacking. This study evaluated the frequency of irAEs among a large population of patients with non-small cell lung cancer (NSCLC) who received immune checkpoint inhibitors. Methods: Administrative claims data from a large U.S. commercial insurance database (OptumLabs Data Warehouse) were used to retrospectively identify patients with NSCLC who received PD-1 or PD-L1 inhibitors between January 1, 2015 to December 31, 2017. The frequencies of irAEs were reported, identified by having a new medical claim with a corresponding ICD-9 or ICD-10 code during the time period in which the patient was on immunotherapy. Results: Of 2,798 patients with NSCLC (median age at PD-(L)1 initiation: 69 years, interquartile range: 60-75, 1558 male [55.7%], 1240 [44.3%] female), 1,998 (71.4%) received nivolumab, 699 (25.0%) received pembrolizumab, and 101 (3.6%) received atezolizumab. Most patients (1463, 52.3%) received a PD-(L)1 inhibitor as second line therapy; the majority of patients (744) received alkylating agents and antimetabolites prior to receiving PD-(L)1 therapy. See Table 1 for frequencies of irAEs. Conclusions: The current study suggests that the frequencies of some irAEs related to immune checkpoint inhibitor therapies may be higher than those which were reported in the initial trials that led to the FDA approvals for immunotherapies. For example, hypophysitis was noted to occur in 0.6% of patients in the KEYNOTE-024 trial, but was identified in 2.4% of patients in this large cohort. Real world data may refine provider and patient expectations for outcomes beyond what is observed in clinical trials. [Table: see text]