Treatment Invasiveness and Illness Perceptions Are Strongly Associated With Outcome Expectations in Patients Treated for Hand or Wrist Conditions: A Cross-sectional Study.

BACKGROUND: Multiple studies have shown that more-positive outcome expectations are associated with better treatment outcomes. Although this has not been shown to represent a causal relationship, there nonetheless is an interest in positively modifying outcome expectations to improve treatment outcomes. However, little is known about what is independently associated with outcome expectations in clinical practice. For example, it is unknown to what extent expectations are associated with treatment or patient characteristics such as sociodemographics or with patient-reported outcome measures (PROMs) on patient perceptions of physical or mental health or illness. Studying factors associated with outcome expectations may provide relevant information for clinicians and researchers aiming to improve outcome expectations. Improving expectations might, in turn, improve treatment outcomes. QUESTION/PURPOSE: Which factors (that is, sociodemographics, PROMs, illness perceptions, treatment, surgeon, and location) are independently associated with outcome expectations in patients with hand or wrist conditions? METHODS: This was a cross-sectional study. Between July 2018 and December 2021, we screened 21,327 patients with a diagnosed hand or wrist condition with complete baseline sociodemographic data such as age and workload. Sixty percent (12,765 of 21,327) of patients completed all relevant PROMs. We excluded patients receiving rare treatments, leaving 58% (12,345 of 21,327) for inclusion in the final sample. Those who participated were more often scheduled for surgical treatment and had higher expectations. We performed a multilevel analysis involving two steps. First, we evaluated whether patients receiving the same treatment, being counseled by the same surgeon, or being treated at the same location have more similar outcome expectations. We found that only patients receiving the same treatment had more similar outcome expectations. Therefore, we used a multilevel regression model to account for this correlation within treatments, and added treatment characteristics (such as nonsurgical versus minor or major surgery) to potential explanatory factors. Second, in the multilevel hierarchical regression analysis, we added sociodemographics (Model 1), PROMs for physical and mental health (Model 2), illness perceptions (Model 3), and treatment characteristics (most-definitive model) to assess the explained variance in outcome expectations per step and the relative association with outcome expectations. RESULTS: Sociodemographic factors such as age and workload explained 1% of the variance in outcome expectations. An additional 2% was explained by baseline PROMs for physical and mental health, 9% by illness perceptions, and 18% by treatment characteristics, resulting in an explained variance of 29% of the most-definitive model. A large number of patient and treatment characteristics were associated with outcome expectations. We used standardized betas to compare the magnitude of the effect of the different continuous and categorical variables. Among the associated variables, minor surgery (standardized beta [ß] = 0.56 [95% confidence interval 0.44 to 0.68]; p < 0.001) and major surgery (ß = 0.61 [95% CI 0.49 to 0.73]; p < 0.001) had the strongest positive association with outcome expectations (receiving surgery is associated with higher outcome expectations than nonsurgical treatment). A longer illness duration expected by the patient (-0.23 [95% CI -0.24 to -0.21]; p < 0.001) and being treated for the same condition as before (-0.08 [95% CI -0.14 to -0.03]; p = 0.003) had the strongest negative association with outcome expectations. CONCLUSION: Outcome expectations are mainly associated with the invasiveness of the treatment and by patients' illness perceptions; patients before surgical treatment have more positive expectations of the treatment outcome than patients before nonsurgical treatment, even after accounting for differences in clinical and psychosocial profiles. In addition, patients with a more-positive perception of their illness had more-positive expectations of their treatment. Our findings suggest expectation management should be tailored to the specific treatment (such as surgical versus nonsurgical) and the specific patient (including their perception of their illness). It may be more beneficial to test and implement expectation management strategies for nonsurgical treatments such as physical therapy than for surgical treatments, given that our findings indicate a greater need to do so. An additional advantage of such a strategy is that successful interventions may prevent converting to surgical interventions, which is a goal of the stepped-care principles of standard care. Future studies might investigate the causality of the association between pretreatment expectations and outcomes by performing an experimental study such as a randomized controlled trial, in which boosting expectations is compared with usual care in nonsurgical and surgical groups. LEVEL OF EVIDENCE: Level III, prognostic study.

Involvement in a Personal Injury Claim Is Associated With More Pain and Delayed Return to Work After Elective Nonsurgical or Surgical Treatment for Hand or Wrist Disorders: A Propensity Score-matched Comparative Study.

BACKGROUND: A small proportion of patients treated for a hand or wrist condition are also involved in a personal injury claim that may or may not be related to the reason for seeking treatment. There are already indications that patients involved in a personal injury claim have more severe symptoms preoperatively and worse surgical outcomes. However, for nonsurgical treatment, it is unknown whether involvement in a personal injury claim affects treatment outcomes. Similarly, it is unknown whether treatment invasiveness affects the association between involvement in a personal injury claim and the outcomes of nonsurgical treatment. Finally, most studies did not take preoperative differences into account. QUESTIONS/PURPOSES: (1) Do patients with a claim have more pain during loading, less function, and longer time to return to work after nonsurgical treatment than matched patients without a personal injury claim? (2) Do patients with a personal injury claim have more pain, less function, and longer time to return to work after minor surgery than matched patients without a personal injury claim? (3) Do patients with a personal injury claim have more pain, less function, and longer time to return to work after major surgery than matched patients without a personal injury claim? METHODS: We used data from a longitudinally maintained database of patients treated for hand or wrist disorders in the Netherlands between December 2012 and May 2020. During the study period, 35,749 patients for whom involvement in a personal injury claim was known were treated nonsurgically or surgically for hand or wrist disorders. All patients were invited to complete the VAS (scores range from 0 to 100) for pain and hand function before treatment and at follow-up. We excluded patients who did not complete the VAS on pain and hand function before treatment and those who received a rare treatment, which we defined as fewer than 20 occurrences in our dataset, resulting in 29,101 patients who were eligible for evaluation in this study. Employed patients (66% [19,134 of 29,101]) were also asked to complete a questionnaire regarding return to work. We distinguished among nonsurgical treatment (follow-up at 3 months), minor surgery (such as trigger finger release, with follow-up of 3 months), and major surgery (such as trapeziectomy, with follow-up at 12 months). The mean age was 53 ± 15 years, 64% (18,695 of 29,101) were women, and 2% (651 of 29,101) of all patients were involved in a personal injury claim. For each outcome and treatment type, patients with a personal injury claim were matched to similar patients without a personal injury claim using 1:2 propensity score matching to account for differences in patient characteristics and baseline pain and hand function. For nonsurgical treatment VAS analysis, there were 115 personal injury claim patients and 230 matched control patients, and for return to work analysis, there were 83 claim and 166 control patients. For minor surgery VAS analysis, there were 172 personal injury claim patients and 344 matched control patients, and for return to work analysis, there were 108 claim and 216 control patients. For major surgery VAS analysis, there were 129 personal injury claim patients and 258 matched control patients, and for return to work analysis, there were 117 claim and 234 control patients. RESULTS: For patients treated nonsurgically, those with a claim had more pain during load at 3 months than matched patients without a personal injury claim (49 ± 30 versus 39 ± 30, adjusted mean difference 9 [95% confidence interval (CI) 2 to 15]; p = 0.008), but there was no difference in hand function (61 ± 27 versus 66 ± 28, adjusted mean difference -5 [95% CI -11 to 1]; p = 0.11). Each week, patients with a personal injury claim had a 39% lower probability of returning to work than patients without a claim (HR 0.61 [95% CI 0.45 to 0.84]; p = 0.002). For patients with an injury claim at 3 months after minor surgery, there was more pain (44 ± 30 versus 34 ± 29, adjusted mean difference 10 [95% CI 5 to 15]; p < 0.001), lower function (60 ± 28 versus 69 ± 28, adjusted mean difference -9 [95% CI -14 to -4]; p = 0.001), and 32% lower probability of returning to work each week (HR 0.68 [95% CI 0.52 to 0.89]; p = 0.005). For patients with an injury claim at 1 year after major surgery, there was more pain (36 ± 29 versus 27 ± 27, adjusted mean difference 9 [95% CI 4 to 15]; p = 0.002), worse hand function (66 ± 28 versus 76 ± 26, adjusted mean difference -9 [95% CI -15 to -4]; p = 0.001), and a 45% lower probability of returning to work each week (HR 0.55 [95% CI 0.42 to 0.73]; p < 0.001). CONCLUSION: Personal injury claim involvement was associated with more posttreatment pain and a longer time to return to work for patients treated for hand or wrist disorders, regardless of treatment invasiveness. Patients with a personal injury claim who underwent surgery also rated their postoperative hand function as worse than similar patients who did not have a claim. Depending on treatment invasiveness, only 42% to 55% of the personal injury claim patients experienced a clinically relevant improvement in pain. We recommend that clinicians extensively discuss the expected treatment outcomes and the low probability of a clinically relevant improvement in pain with their personal injury claim patients and that they broach the possibility of postponing treatment. LEVEL OF EVIDENCE: Level III, therapeutic study.