Journal Club Article, December 2019

Do positive health care experiences result in better outcomes?

Schrier V et al: Better patient-reported experiences with health care are associated with improved clinical outcome after carpal tunnel release surgery. Plastic and Reconstructive Surgery, 2019; 143:1677-1686.  

Tsehaie J et al: Positive experience with treatment is associated with better surgical outcome in trapeziometacarpal osteoarthritis. Journal of Hand Surgery, European, 2019, J Hand Surg Eur Sep;44(7):714-721.

Patient-reported outcome measures (PROMs) such as the Disabilities of Arm, Shoulder, and Hand Questionnaire, the Michigan Hand Outcomes Questionnaire, and the Boston Carpal Tunnel Assessment Questionnaire are commonly used measures to assess procedural results from the patient’s perspective. When used preoperatively and again postoperatively, PROMs indicate the patient’s perspective on symptom relief and functional restoration, which may be different from the classically studied objective measures such as joint motion, two-point discrimination, and pinch strength.

New, at least as applied to hand conditions, are the use of patient-reported experience measures (PREMs), which assess patients’ perspectives on the health care process. These factors include the quality of the hand care professionals’ guidance before and after surgery, the level of listening and understanding, and the clinic’s accessibility and cleanliness.

So the question arises, are PROMs and PREMs related? In other words, is a satisfactory experience the prelude to a good result?

Two recent studies, one on carpal tunnel release (CTR) and the other on trapeziometacarpal arthroplasty (TMA) for osteoarthritis, attempt to identify a relationship between experience and outcome. Both studies were prospective, took place in the Netherlands, and had some overlap of authors.

The CTR study involved 1607 patients, each of whom completed the Boston Carpal Tunnel Assessment Questionnaire before surgery and again three months after surgery when the patients also completed an experience questionnaire that included six subscales on different healthcare delivery aspects (eg physician communication and guidance, perioperative care, and hand therapist guidance and information before and after surgery).

The TMA study included 233 patients, all of whom received the same surgical procedure and who completed the Michigan Hand Outcomes Questionnaire before surgery and twelve months after surgery. Three months after surgery these patients also completed an experience survey that was nearly identical to the one used in the CTR study.

In both studies, the authors performed detailed statistical analyses and concluded that the differences noted between the pre- and post-op PROMs were correlated with the PREMS. Indeed, the patients with better experiences had better outcomes.

When the PREM results were divided into the six subscales, several trends emerged. Time spent with the healthcare provider proved to be less important than the quality of the conversation—quality trumped quantity. Treatment information, which removed uncertainty regarding expectations, also was strongly correlated with a better outcome.

In a way, the findings are intuitive. An anxious, isolated patient may develop catastrophic thinking. But before we all rush to add wine bars and BarcaLoungers to our waiting rooms in an effort to heighten our patients’ experiences, an important caveat is in order. Both studies point out that although they found a correlation between PREMs and PROMs, neither study proved that better PREMs resulted in better PROMs. It might be that better PROMs resulted in better PREMs. In other words, a patient with a good final result could easily, in retrospect, recall the experience as being satisfying; whereas a patient enduring complications might remember every little inconvenience and uncertainty that occurred along the way. Or maybe the investigators found that PREMs and PROMs were correlated because both measures assessed the same underlying concepts–the type of patients who generally feel good may likely feel well-treated and are generally optimistic. 

There are many weaknesses in both studies, including not measuring symptom severity or duration nor comorbidities such as diabetes or worker compensation status. Nonetheless, I found the papers interesting reading and food for thought. The placebo effect of a personal, trusting relationship likely contributes to greater treatment adherence and improved health, and we will likely see follow-on studies to explore in depth the relationship between outcomes and experiences. As classically stated, the success of healthcare providers relates to availability, affability, and capability, in that order.