Associations between Patient Expectations and Recovery Outcomes

Physical and social functioning following serious illness has been shown to correlate with patient expectations for recovery. However, evidence showing the impact of expectations on clinical outcomes is limited. Prior studies have examined the links between recovery expectations and rehabilitation outcomes, including self-reported well-being, functional status, and return to work, but there are few studies documenting possible associations between expectations and subsequent clinical events. Researchers recently conducted a study to examine the prognostic effects of recovery expectations in a cohort of patients with coronary artery disease who had a detailed baseline medical and psychosocial evaluation and extensive follow-up. The study examined the effect of beliefs of patients undergoing coronary angiography about their prognosis as predictors of outcomes, including long-term survival and functional status at 1 year following the procedure. Outcomes were total mortality, cardiovascular mortality, and 1-year functional status. Study results were reported in Archives of Internal Medicine [2011;171(10):929-935]. Baseline measures for the study included the Expectations for Coping Scale (ECS), a measure that included 18 questions about the patient’s expectations regarding future lifestyle and future cardiac prognosis. Half of the questions were worded so that agreement implied positive expectations and half were worded so that agreement implied negative expectations. Of a possible range of 0 to 90, the mean baseline score was 63. Severity of disease was controlled by including the number of coronary arteries with at least 75% stenosis, left ventricular ejection fraction, and a 6-level variable indicating the presence and severity of congestive heart failure. Functional status at baseline was determined utilizing the Duke Activity Status Index, a scale that measures a patient’s ability to perform 12 activities that range in strenuousness from self-care and walking around the house to lifting heavy furniture. Basic mortality analyses were conducted on data from 2818 patients. The analyses controlled for age, sex, disease severity, comorbidities, social support, and functional status. Of the 2828 patients, 1637 died during the 15-year follow-up, 885 from cardiovascular causes. ECS scores indicating positive expectations were associated with reduced mortality risk for both total mortality and cardiac mortality, despite controls for clinical disease indicators (model 1) plus potentially confounding psychosocial variables (model 2). For a difference equivalent to an interquartile range of expectations, the hazard ratio (HR) for total mortality was 0.76 (95% confidence interval [CI], 0.71-0.82) and 0.76 (95% CI, 0.69-0.83) for cardiovascular mortality. When income was substituted for education as the covariate in the total mortality model 2, the results were essentially the same (HR, 0.84; 95% CI, 0.77-0.91 for ECS). Analyses for functional status yielded similar associations (P<.001). Study limitations cited by the researchers include the possibility that both expectations and survival are associated with some unmeasured confounders, such as unmeasured risk factors or differential treatment by physicians and staff that may affect expectations. Selection bias may also be a limitation: patients were excluded if they had missing data, did not qualify, or did not agree to participate. Those patients are different from those who did participate, and the findings may not be generalizable to them, particularly for the follow-up functional status outcome. In conclusion, the researchers said that “patients with coronary artery disease who had more favorable expectations about their likelihood of recovery and return to a normal lifestyle had better long-term survival as well as better functional status after their hospitalization.”