Background/Purpose:

A previous study examining patients’ expectations of elective foot and ankle surgery found that race is significantly associated with expectations. In this study, using a patient-derived institutional Foot & Ankle Surgery Expectations Survey, we aimed to examine the relationship between patients’ preoperative expectations and census tract (CT) socioeconomic factors in addition to race.  

Methods:

All adult patients scheduled for elective foot or ankle surgery by one of six orthopedic surgeons were screened for inclusion between August 2015 and March 2016. Preoperatively, patients completed the Foot & Ankle Surgery Expectations Survey, which contains 23 expectations categories, each rated on a 5-point Likert scale ranging from “I do not have this expectation” to “complete improvement expected”, with higher scores (range 1-23) indicating greater expectations. Using geocoding, individual-level registry data was linked to US census tracts data through patient addresses. Simple and multiple linear regression were used to model expectations scores as a function of individual race, and CT  median income,  Gini coefficient, and percentages of blacks, Hispanics, residents living below poverty, residents living alone, residents with insurance coverage, and residents with Medicaid coverage.  The multiple linear regression model used backward selection methodology, requiring 0.05 significance to remain in the final model. An interaction between race and CT poverty was assessed.

Results:

352 patients (mean age 55±14 years, 66% female) were included in this study. Factors that were significantly associated with higher expectations in univariate modeling were  non-Caucasian race, female sex, and census tract percentage of blacks, census tract percentage of Hispanics, census tract percentage of residents with Medicaid insurance, census tract poverty level, and census tract Gini coefficient (all p<0.05, Table 1). In multivariable modeling, females scored 5 points higher (5.00±1.93, p=0.01) on the Expectations Survey than males. Caucasians scored nearly 11 points lower (-10.98±3.13, p<0.001) than non-whites. There were no community CT variables that remained significant, and there was no interaction between race and CT poverty (p=0.7).

Conclusion:

Among patients undergoing diverse procedures in foot and ankle surgery, we found that female sex and non-Caucasian race were independently associated with higher expectations, but community social factors were not significant. These findings may help inform surgeons’ preoperative discussions as they address patients’ expectations. Future studies are needed to explore whether preoperative expectations scores correlate with postoperative satisfaction, and whether the factors that affect expectations also affect satisfaction.