PATIENT SELECTED GOALS: A NEW PERSPECTIVE ON SURGICAL OUTCOME

E. Elkadry, K. Kenton, MP. FitzGerald, S. Shott, L. Brubaker

   Objective:  To study interactions between patient-selected goals, overall satisfaction and traditional outcome measures for reconstructive surgery.

   Materials and Methods: In an IRB-approved protocol, we prospectively followed 78 women who underwent pelvic reconstructive surgery between January and May of 2002. After giving informed consent for surgery, participants were contacted by the physician investigator. Pre-operatively, goals for the surgery were selected and negotiated to modify goals that were not achievable in the physician’s opinion. The same physician contacted these women three months after surgery to assess goal achievement, overall satisfaction and their surgical experience. Objective success was defined by the POP-Q and standardized urodynamic testing. Overall satisfaction was expressed by percentage satisfied and a five-point scale measured goal achievement. We used Spearman’s correlation and Mann Whitney tests.

   Results: Patients had a mean of 3.62 goals (1-8). Fifty-eight percent and 52% of patients expressed urinary and prolapse goals respectively. Fifty percent and 43% expressed general lifestyle and activity goals. Postoperatively, 75% of women indicated that they met all or most of their goals. Seventy-two percent reported at least 80% overall satisfaction. Eighty three percent reported that their symptoms were better or very much better after surgery and 83% said they would have had the surgery again. The number of goals met did not relate to satisfaction, but patients with more goals were more likely to meet at least a few. Patient satisfaction was not correlated to achievement of patient-selected goals (Spearman’s r= .03; P< 0.8). Normal catheter duration was frequently viewed as a “complication” and associated with decreased satisfaction. Prolonged return to normal activities and presence of urinary symptoms (especially urge incontinence) decreased satisfaction (p=0.!
007) and goal achievement (p=0.001). Urge incontinence and/or voiding dysfunction affect satisfaction and goal achievement more than objective stress incontinence cure. Objective cure of prolapse has no effect on patient satisfaction or goal achievement (P< 0.14). Post-operative dissatisfaction was highly associated with “feeling unprepared for surgery” (p<0.001). The need for re-operation or other complication was associated with a decrease in patient satisfaction despite a lack of effect on the proportion of goals met. Patients with poorer health status or depression tended to achieve fewer goals.

   Conclusion: Objective cure does not mean “successful surgery”. Common measures of surgical outcome do not predict patient satisfaction. . Rapid return to normal lifestyle affects perception of success even when patients do not state lifestyle goals. More detailed explanations of side effects and post-operative expectations are recommended prior to surgery.