Johannes A. C. Laferton

Patients’ Expectations Regarding Medical Treatment: A Critical Review of Concepts and Their Assessment

Patients’ expectations in the context of medical treatment represent a growing area of research, with accumulating evidence suggesting their influence on health outcomes across a variety of medical conditions. However, the aggregation of evidence is complicated due to an inconsistent and disintegrated application of expectation constructs and the heterogeneity of assessment strategies. Therefore, based on current expectation concepts, this critical review provides an integrated model of patients’ expectations in medical treatment. Moreover, we review existing assessment tools in the context of the integrative model of expectations and provide recommendations for improving future assessment. The integrative model includes expectations regarding treatment and patients’ treatment-related behavior. Treatment and behavior outcome expectations can relate to aspects regarding benefits and side effects and can refer to internal (e.g., symptoms) and external outcomes (e.g., reactions of others). Furthermore, timeline, structural and process expectations are important aspects with respect to medical treatment. Additionally, generalized expectations such as generalized self-efficacy or optimism have to be considered. Several instruments assessing different aspects of expectations in medical treatment can be found in the literature. However, many were developed without conceptual standardization and psychometric evaluation. Moreover, they merely assess single aspects of expectations, thus impeding the integration of evidence regarding the differential aspects of expectations. As many instruments assess treatment-specific expectations, they are not comparable between different conditions. To generate a more comprehensive understanding of expectation effects in medical treatments, we recommend that future research should apply standardized, psychometrically evaluated measures, assessing multidimensional aspects of patients’ expectations that are applicable across various medical treatments. In the future, more research is needed on the interrelation of different expectation concepts as well as on factors influencing patients’ expectations of illness and treatment. Considering the importance of patients’ expectations for health outcomes across many medical conditions, an integrated understanding and assessment of such expectations might facilitate interventions aiming to optimize patients’ expectations in order to improve health outcomes.

Optimizing preoperative expectations in cardiac surgery patients is moderated by level of disability: the successful development of a brief psychological intervention

Patients’ expectations have shown to be a major psychological predictor of health outcome in cardiac surgery patients. However, it is unclear whether patients’ expectations can be optimized prior to surgery. This study evaluates the development of a brief psychological intervention focusing on the optimization of expectations and its effect on change in patients’ expectations prior to cardiac surgery. Ninety patients scheduled for coronary artery bypass graft were randomly assigned to (1) standard medical care, (2) additional expectation manipulation intervention (EMI), and (3) additional attention control group. Therapists’ fidelity to intervention manuals and patients satisfaction with the intervention were assessed for both active intervention conditions. Patients’ expectations about post-surgical disability, treatment control, personal control, and disease duration were assessed before and after the psychological intervention. Demographical, medical, and psychosocial characteristics and disability were assessed at baseline. Treatment fidelity and patient satisfaction was very high in both intervention conditions. Only patients receiving EMI developed higher personal control expectations and longer (more realistic) expectations of disease duration. The effect of intervention group on patients’ disability expectations and patients’ personal control expectations was moderated by patient’s level of disability. EMI patients with low to moderate disability developed positive expectations whereas patients with high disability did not. This study shows the successful development of a short psychological intervention that was able to modify patients’ expectations, especially in those with low to moderate disability. Given the robust association of expectations and surgery outcome, such an intervention might offer the opportunity to enhance patients’ health following cardiac surgery.

Factors Associated with Disability Expectations in Patients Undergoing Heart Surgery

BackgroundHeart surgery patients’ expectations have been shown to be related to surgery outcome, independent of medical status. However, it is unclear which factors determine patients’ expectations about disability following heart surgery.PurposeInvestigating the associations of patients’ disability expectations with demographic, medical, and psychosocial factors as well as other aspects of patients’ expectations might help to tailor psychological interventions more specifically to optimize patient’s expectations.MethodsEighty-three patients were invited to a psycho-educational intervention to optimize expectations prior to elective coronary artery bypass graft (CABG). Before the psychological intervention and before surgery, disability expectations, demographical, medical, psychosocial variables as well as patient and treatment related expectations were collected via questionnaires and patients’ files. Associations with disability expectations were assessed using hierarchical linear multiple regression analysis.ResultsPatients self-rated disability (β = 0.50; p < 0.001) and beliefs about treatment efficacy (β = −0.42; p < 0.001) was independently associated with disability expectations. Expectations about the efficacy of patients’ own health behavior as well as demographical variables, psychological distress, perceived social support, and measures of medical morbidity did not explain any additional variance in patients’ disability expectations.ConclusionCABG patients seem to form their disability expectations upon their perceptions about their current disability and their expectations about the efficacy of treatment. Patients’ disability expectations appear to be independent from scientifically established risk factors and other psychosocial patient characteristics in heart surgery. Future research is necessary to further determine what factors psychological interventions should focus on to modify patients’ disability expectations.

Patientenerwartungen optimieren: Beschreibung einer präoperativen Kurzintervention am Beispiel von Patienten vor einer Bypass-Operation

Hintergrund: Patientenerwartungen gelten als wichtige Wirkmechanismen bei psychotherapeutischen und medizinischen Behandlungen und spielen für die Genesung eine große Rolle. Vor diesem Hintergrund wurde eine psychologische präoperative Kurzintervention zur Erwartungsoptimierung entwickelt, um den Genesungsprozess nach Herzoperationen positiv zu beeinflussen. Dieser Artikel beschreibt die psychologische Kurzintervention (EXPECT) und stellt Evaluationsergebnisse der Intervention aus Patientensicht dar. Patienten und Methoden: 124 herzchirurgische Patienten wurden randomisiert und einer von drei Interventionen zugeteilt: a) Erwartungsoptimierung, b) supportive Therapie oder c) ausschließlich medizinische Standardbehandlung. In der Erwartungsintervention, die 2 Sitzungen und 2 Telefonate vor der Operation umfasst, wurden systematisch verhaltens- und behandlungsbezogene Ergebniserwartungen optimiert. Die Patienten wurden mithilfe von Fragebögen zu ihrer Zufriedenheit mit der Intervention befragt. Mittelwerte wurden berechnet. Ergebnisse: Die Zufriedenheit der Patienten mit beiden psychologischen Interventionen war im Mittel hoch bis sehr hoch. In der Erwartungsinterventionsgruppe fühlten sich die Patienten noch besser informiert und erwarteten einen positiveren Heilungsverlauf als die Patienten, die eine supportive Therapie erhielten. Ein Großteil der Patienten erlebte die Interventionen als hilfreich und erwartete durch diese positivere Ergebnisse, was sich auch im längsschnittlichen Verlauf bestätigte. Somit können präoperative Interventionen bei herzchirurgischen Eingriffen das bestehende Behandlungsangebot sinnvoll erweitern. Schlussfolgerungen: Die Optimierung von verhaltens- und ergebnisbezogenen Patientenerwartungen vor der eigentlichen Intervention kann zu einer Verbesserung von Behandlungsergebnissen beitragen. Eine solche psychologische Intervention wird gut angenommen und ist im Rahmen eines herzchirurgischen Settings durchführbar. Die Förderung positiver Erwartungen und die Veränderung ungünstiger Ausgangserwartungen von Patienten sollten sowohl bei psychotherapeutischen als auch bei herzchirurgischen Behandlungen stärker berücksichtigt werden.

Optimizing expectations and distraction leads to lower cortisol levels after acute stress

BACKGROUND A new approach of psychological interventions prior to stress aiming to optimize expectations may have beneficial effects on a persons health status by reducing physiological stress. The purpose of this experiment was to determine whether a brief psychological intervention designed to optimize personal control expectations prior to acute stress would affect perceived and biological stress responsiveness in comparison to two more established interventions (fostering gratitude or distraction) in a healthy sample. METHODS 74 healthy participants were randomized to one of three psychological interventions prior to stress: (i) writing about ways to influence stress to optimize personal control expectations (EXPECTATION), (ii) writing a gratitude-letter (GRATITUDE) (iii) or a distraction writing task (DISTRACTION). After completing the intervention, the Maastricht acute stress test was administered to induce (psychosocial and physiological) stress. Assessments took place at baseline, post-intervention (15 min writing task) and after stress induction (additional salivary assessments: 15 and 30 min after stress). Main outcomes were expectations, emotions, perceived stress, salivary cortisol and alpha-amylase. Personality traits (eg, optimism) were assessed at baseline. RESULTS EXPECTATION specifically increased personal control expectations (p = .016, d = .72) and GRATITUDE specifically increased gratitude (p = .026, d = .68). EXPECTATION and DISTRACTION led to lower cortisol concentrations after stress induction than GRATITUDE (time x group interaction: p < .001, d = .88). We detected no intervention effects on alpha-amylase or perceived stress. Optimism moderated intervention effects on cortisol (p = .023, d = .74). CONCLUSIONS Brief psychological interventions aiming to optimize expectations or distraction prior to stress reduce the cortisol response in healthy participants after an acute stressor.