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Table 1. 
Patient Characteristics
Patient Characteristics
Table 2. 
Expected Improvement and Expectation-Outcome Discrepancy forVisual Function Index (VF-14) Items
Expected Improvement and Expectation-Outcome Discrepancy forVisual Function Index (VF-14) Items
Table 3. 
Spearman Rank Correlations With Patient Satisfaction for VisualFunction Index (VF-14) Items*
Spearman Rank Correlations With Patient Satisfaction for VisualFunction Index (VF-14) Items*
Table 4. 
Spearman Correlations With Patient Satisfaction for CompositeMeasures
Spearman Correlations With Patient Satisfaction for CompositeMeasures
Table 5. 
Multiple Regression of Predictors of Patient Satisfaction
Multiple Regression of Predictors of Patient Satisfaction
1.
Scott  ASmith  RD Keeping the customer satisfied: issues in the interpretation and useof patient satisfaction surveys. Int J Qual Health Care 1994;6353- 359
PubMedArticle
2.
Epstein  AM The outcomes movement: will it get us where we want to go? N Engl J Med 1990;323266- 270
PubMedArticle
3.
Feinstein  ARJosephy  BRWells  CK Scientific and clinical problems in indexes of functional disability. Ann Intern Med 1986;105413- 420
PubMedArticle
4.
Cleary  PDMcNeil  BJ Patient satisfaction as an indicator of quality of care. Inquiry 1988;2525- 36
PubMed
5.
Fitzpatrick  R Survey of patient satisfaction, I: important general considerations. BMJ 1991;302887- 889
PubMedArticle
6.
Donabedian  A The quality of care: how can it be assessed? JAMA 1988;2601743- 1748
PubMedArticle
7.
Aharony  LStrasser  S Patient satisfaction: what we know about and what we still need toexplore. Med Care Rev 1993;5049- 79
PubMedArticle
8.
Padberg  RMPadberg  LF Strengthening the effectiveness of patient education: applied principlesof adult education. Oncol Nurs Forum 1990;1765- 69
PubMed
9.
Hall  JADornan  MC Meta-analysis of satisfaction with medical care: description of researchdomain and analysis of overall satisfaction levels. Soc Sci Med 1988;27637- 644
PubMedArticle
10.
Williams  B Patient satisfaction: a valid concept? Soc Sci Med 1994;38509- 516
PubMedArticle
11.
Yucelt  U An investigation of causes of patient satisfaction/dissatisfactionwith physician services. Health Mark Q 1994;1211- 28
PubMedArticle
12.
Angelopoulou  PKangis  PBabis  G Private and public medicine: a comparison of quality perceptions. Int J Health Care Qual Assur Inc Leadersh Health Serv 1998;1114- 20
PubMedArticle
13.
Ware  JEDavies  AR Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann 1983;6291- 297
PubMedArticle
14.
Rubin  HRGandek  BRogers  WHKosinski  MMcHorney  CAWare  JE Patients' ratings of outpatient visits in different practice settings:results from the Medical Outcomes Study. JAMA 1993;270835- 840
PubMedArticle
15.
Rubin  HR Can patients evaluate the quality of hospital care? Med Care Rev 1990;47267- 326
PubMedArticle
16.
Zeithaml  VAParasuraman  ABerry  LL Delivering Quality Service: Balancing Customer Perceptionsand Expectations.  New York, NY T Free Press1990;
17.
Messner  RLLewis  SJ Increasing Patient Satisfaction: A Guide for Nurses.  New York, NY Springer1996;
18.
Carr-Hill  RA The measurement of patient satisfaction. J Public Health Med 1992;14236- 249
PubMed
19.
Thompson  AGSunol  R Expectations as determinants of patient satisfaction: concepts, theoryand evidence. Int J Qual Health Care 1995;7127- 141
PubMed
20.
Flood  ABLorence  DPDing  JMcPherson  KBlack  NA The role of expectations in patients' reports of post-operativeoutcomes and improvement following therapy. Med Care 1993;311043- 1056
PubMedArticle
21.
Fitzpatrick  RHopkins  A Problems in the conceptual framework of patient satisfaction research:an empirical exploration. Sociol Health Illn 1983;5297- 311
PubMedArticle
22.
Draper  MHill  S The Role of Patient Satisfaction Surveys in a NationalApproach to Hospital Quality Management.  Melbourne Australian Government Publishing Service1995;
23.
Linder-Pelz  S Toward a theory of patient satisfaction. Soc Sci Med 1982;16577- 582
PubMedArticle
24.
Linder-Pelz  S Social psychological determinants of patient satisfaction: a test offive hypotheses. Soc Sci Med 1982;16583- 589
PubMedArticle
25.
Egbert  LDBattit  GEWelch  CE  et al.  Reeducation of post-operative pain: encouragement and instruction topatients. N Engl J Med 1964;270825- 827
PubMedArticle
26.
Taylor  HR Cataract: how much surgery do we have to do? Br J Ophthalmol 2000;841- 2
PubMedArticle
27.
Westcott  MCTuft  SJMinassian  DC Effect of age on visual outcome following cataract extraction. Br J Ophthalmol 2000;841380- 1382
PubMedArticle
28.
American Academy of Ophthalmology, Preferred Practice Pattern: Cataract in the AdultEye.  San Francisco Calif American Academy of Ophthalmology2001;8
29.
McCarty  CAKeeffe  JETaylor  HR The need for cataract surgery: projections based on lens opacity, visualacuity, and personal concern. Br J Ophthalmol 1999;8362- 65
PubMedArticle
30.
World Health Organization, Global Initiative for the Elimination of AvoidableBlindness: An Informal Consultation.  Geneva, Switzerland World Health Organization1997;WHO/PBL/97.61
31.
Keeffe  JETaylor  HR Cataract surgery in Australia 1985-94. Aust N Z J Ophthalmol 1996;24313- 317
PubMedArticle
32.
Batterbury  MKhaw  PTHands  R  et al.  The cataract explosion: the changing pattern of diagnoses of patientsattending an ophthalmic outpatient department. Eye 1991;5369- 372
PubMedArticle
33.
Friedman  DSSchein  OD Assessing disability in the patient with cataract. Curr Opin Ophthalmol 1998;91- 4
PubMedArticle
34.
Legro  MW Quality of life and cataracts: a review of patient-centered studiesof cataract surgery outcomes. Ophthalmic Surg 1991;22431- 443
PubMed
35.
McCarty  CANanjan  MBTaylor  HR Operated and unoperated cataract in Australia. Clin Experiment Ophthalmol 2000;2877- 82
PubMedArticle
36.
Keeffe  JEMcCarty  CAChang  WPSteinberg  EPTaylor  HR Relative importance of visual acuity, patient concern and patient lifestyleon referral for cataract surgery [ARVO abstract 871]. Invest Ophthalmol Vis Sci 1996;37S183
37.
Mangione  CMPhillips  RSLawrence  MG  et al.  Improved visual function and attenuation of declines in health-relatedquality of life after cataract extraction. Arch Ophthalmol 1994;1121419- 1425
PubMedArticle
38.
Alonso  JEspallargues  MAndersen  TF  et al.  International applicability of the VF-14: an index of visual functionin patients with cataracts. Ophthalmology 1997;104799- 807
PubMedArticle
39.
Cassard  SDPatrick  DLDamiano  AM  et al.  Reproducibility and responsiveness of the VF-14: an index of functionalimpairment in patients with cataracts. Arch Ophthalmol 1995;1131508- 1513
PubMedArticle
40.
Tielsch  JMSteinberg  EPCassard  SD  et al.  Preoperative functional expectations and postoperative outcomes amongpatients undergoing first eye cataract surgery. Arch Ophthalmol 1995;1131312- 1318
PubMedArticle
41.
Lundstrom  MBarry  PLeite  ESeward  H  et al.  1998 European Cataract Outcome Study: report from the European CataractOutcome Study Group. J Cataract Refract Surg 2001;271176- 1184
PubMedArticle
42.
Chang-Godinich  AOur  RJKoch  DD Functional improvement after phacoemulsification cataract surgery. J Cataract Refract Surg 1999;251226- 1231
PubMedArticle
43.
Capodaglio  EM Comparison between the CR10 Borg's scale and the VAS (visual analoguescale) during an arm-cranking exercise. J Occup Rehabil 2001;1169- 74
PubMedArticle
44.
Bernth-Petersen  P Visual functioning in cataract patients: methods of measuring and results. Acta Ophthalmol (Copenh) 1981;59198- 205
PubMedArticle
Clinical Sciences
December 2004

Expectations and Outcomes in Cataract SurgeryA Prospective Test of 2 Models of Satisfaction

Author Affiliations

Author Affiliation: Department of ClinicalOphthalmology and Eye Health, University of Sydney, Sydney, Australia.

Arch Ophthalmol. 2004;122(12):1788-1792. doi:10.1001/archopht.122.12.1788
Abstract

Objectives  To document patients’ preoperative expectations for postoperativeoutcomes. To measure the relative contribution of patient understanding, expectations,outcome, and expectation-outcome discrepancy in determining patient satisfaction.

Methods  One hundred twenty-one patients were surveyed just before and 1 monthafter cataract surgery regarding their understanding of the procedure, satisfactionwith their vision, and both current and expected visual function for eachof the items on the Visual Function Index (VF-14).

Results  Sixty percent of patients expected to achieve a perfect VF-14 score.The average expected VF-14 score was 96.1, compared with an achieved VF-14score of just 89.8. The most unrealistic expectations involved driving atnight, reading small print, and doing fine handiwork. Surprisingly, improvementin visual function was not correlated with satisfaction in vision. While patientunderstanding, expectations, and achieved VF-14 score did correlate with satisfaction,when controlling for other factors, only achievement-expectation discrepancywas independently predictive.

Conclusions  This study provides support for the expectation-outcome discrepancymodel of patient satisfaction. Further, it highlights the highly unrealisticexpectations harbored by patients with cataract and emphasizes the importancefor physicians to control their patients’ expectations. Controllingpatient expectations may be more effective than improving patients’postoperative outcome in terms of maximizing patient satisfaction.

Patient satisfaction is an increasingly important objective for healthservices.1,2 This trend reflectsthe reality that the choice and success of many treatments are based on subjectivepatient-defined criteria24;that patient satisfaction is an element of health status itself,5,6 withsatisfied patients reporting greater compliance, well-being, and treatmentoutcomes79; thathealth care is increasingly embracing principles of consumerism and autonomy1,10; that health care is becoming increasinglyprivatized and economically competitive,11,12 withsatisfied patients both remaining with and recommending their provider7,1315; andthat a satisfied patient is the best defense against malpractice lawsuits.11

The dominant theoretical model of satisfaction involves meeting patientexpectations, that is, minimizing the expectation-outcome discrepancy. Thisconception of satisfaction has been variously reported as its actual definition11,16,17 or its primary causalfactor.4,10,11,18 Suggestedmechanisms for this effect include cognitive dissonance, patient conditioning,memory and symptom reporting, and anxiety.19,20

However, the importance of expectation-outcome congruence has not alwaysbeen borne out empirically,19,21,22 withthe actual (perceived) outcome18,23 orexpectations alone via the placebo effect10,20,24 accountingfor most of a patient’s satisfaction in some studies. Additionally,the extent to which patients feel adequately informed about their illnesshas been frequently demonstrated as an important and independent determinantof patient satisfaction.1,25

Cataract surgery has increased 400% during the last 10 years26 to become the most common surgical procedure in thedeveloped world,27 exceeding 1.6 million operationsin the United States alone28 because of anaging population29,30 and dramaticexpansion of indications following improvements in technology.31,32 Visualacuity is no longer considered a useful measure of need for surgery,33,34 with patient concern, lifestyle,and subjective reports of function being the primary factors for referral.35,36 Furthermore, cataract surgery ispredominantly delivered through the private health care sector,31 wherepatient satisfaction is of particular consequence.

However, patient satisfaction has rarely been considered in cataractsurgery,34,37 and no studies haveaddressed the role of the hypothesized determinants of patient satisfaction.The objectives of this study are first, to document patients’ preoperativeexpectations for postoperative outcomes and second, to measure the relativecontribution of patient understanding, expectations, outcome, and expectation-outcomediscrepancy in determining patient satisfaction.

METHODS
PATIENTS

One hundred sixty consecutive patients undergoing day-stay cataractsurgery at Sydney Private Hospital, Sydney, Australia, were invited to participatein this study when first registering at the hospital for their surgery. SydneyPrivate Hospital is the largest private provider of cataract surgery in NewSouth Wales and serves a large cross-section of patients from throughout metropolitanSydney. Institutional review board and hospital approval were obtained.

PROCEDURE AND MEASURES

After obtaining informed consent, the patient’s age, sex, visualacuity, and current visual function were recorded by a research interviewer,along with the amount of information the patient had already received regardingthis surgery. Visual function was measured using the Visual Function Index(VF-14),38,39 a widely used scalebased on trouble conducting common binocular activities, with final scoreranging from 0 (no visual ability) to 100 (no visual disability). Patientswere then asked to rate their expected postoperative functional outcome foreach of the 14 items on the VF-14 scale. As part of a related investigation,patients were shown a short video describing either the anatomy of cataractor the procedures experienced during the cataract surgery itself. Neithervideo concerned the postoperative outcomes or expectations that are the subjectof this study. All the data collection occurred 2 to 4 hours prior to surgerybut before the instillation of eye drops, changing of clothes, or any clinicalinduction beyond the registration forms.

On hospital discharge, patients were given an addressed, postage-paidenvelope containing a questionnaire to be completed 1 month after surgery.This questionnaire included the VF-14 and the opportunity for patients torate their degree of understanding and overall satisfaction on a 12-cm visualanalog scale. Patients who did not return their questionnaires were remindedby a follow-up telephone call, and an additional questionnaire and reply envelopewere provided if required.

DATA ANALYSIS

The visual analog scale markings were converted into a scale of 0 to10, and all data were double entered and verified using an Excel spreadsheet,then converted into SPSS for Windows version 11 (SPSS Inc, Chicago, Ill) forfurther analysis.

Spearman rank correlations were used to measure the relationship betweenoverall satisfaction and aspects of expected or achieved visual function (eachitem of the VF-14 is recorded on a 5-point ordinal scale). A multiple regressionwas used to measure the isolated contribution of postoperative function, improvement,and expectation-outcome discrepancy toward predicting satisfaction, whilecontrolling for the other factors. Finally, both Mann-Whitney U and 2-tailed, independent-sample t testswere used to ensure that the preoperative video content had no influence onany of the measured outcomes.

RESULTS

One hundred sixty patients were approached, and 141 (88%) agreed toparticipate. Of these, 121 (85%) returned their 1-month questionnaire. Therewere no differences in preoperative characteristics between these 121 patientsand those who were lost to follow-up (Mann-Whitney U and t tests not shown). The basic preoperative and postoperativecharacteristics of these patients are presented in Table 1. The mean (SD) age was 73.8 (9.2) years, 91 (64.5%) patientswere female, 55 (39%) patients had previous cataract surgery, and the medianvisual acuity was 6/18 in the operative and 6/10 in the nonoperative eye,with a mean (SD) preoperative VF-14 score of 84.7 (14.8) and postoperativeVF-14 score of 89.8 (16.4). There were no preoperative or postoperative differenceson any measure based on video content (Mann-Whitney U and t tests not shown).

PREOPERATIVE EXPECTATIONS

Patients had very high expectations for postoperative function, expectingto achieve a mean (SD) VF-14 score of 96.1 (10.3), representing near-perfectvision and an 11-point expected gain. Eighty-four patients (60%) expectedto achieve a perfect VF-14 score of 100. Only 18 patients did not expect atleast some VF-14 improvement, 12 because their preoperative VF-14 score wasalready 100; the other 6 all had preoperative VF-14 scores higher than 90and expected the same VF-14 score postoperatively.

Table 2 presents for each itemof the VF-14 scale the expected amount of improvement and the expectation-outcomediscrepancy. Driving at night, reading small print, doing fine handiwork,and reading a newspaper or book are the items for which patients expectedthe greatest degree of improvement and for which, not unexpectedly, patients’actual outcomes were the furthest from what they expected. The average expectation-outcomediscrepancy was 6.3 points, with 80 patients (66%) failing to equal or exceedtheir expectations at 1-month follow-up.

Table 3 presents the correlationsbetween patient satisfaction and either actual outcome or expectation-outcomediscrepancy for each item on the VF-14 scale. Actual outcome and satisfactionwere significantly correlated with 11 VF-14 items and more strongly than the6 VF-14 items for which expectation-outcome discrepancy and satisfaction werecorrelated.

Table 4 presents the correlationsbetween patient satisfaction and overall expected improvement, actual improvement,actual outcome, and expectation-outcome discrepancy. Actual outcome was marginallybetter correlated than achievement-outcome discrepancy (0.32 vs 0.28), andthe degree of improvement was not significantly related to patient satisfactionat all.

Table 5 presents a multiple regressionof the significant predictors of patient satisfaction. When controlling foreach other, only the expectation-outcome discrepancy was a significant independentdeterminant of patient satisfaction (standardized β = −0.30; P = .04). Multiple regressions with other configurationsof predictor variables consistently returned expectation-outcome discrepancyas the only independently predictive factor of patient satisfaction.

PATIENT INFORMATION

Before the operation, the majority of patients (115 [81%]) felt at thetime of operation that they “learned as much as I wanted to know”and only 19 (13%) felt that they’d like to have been told more. At 1month, the first group’s mean (SD) overall satisfaction was 8.0 (2.0),which was not significantly different from the second group’s satisfactionof 7.9 (2.0) by Mann-Whitney U test, nor were preoperativeinformation and 1-month postoperative satisfaction significantly correlated.However, the patients’ responses to this preoperative question aboutinformation were narrowly distributed and temporally distant from the 1-monthpostoperative question about satisfaction.

More significantly, patients’ response to the question “howwell did you understand what was happening to you” at 1 month aftersurgery (mean [SD] 8.0 [2.0]) was strongly correlated with patients’postoperative satisfaction (ρ = 0.56; P<.001).

COMMENT

The results of this study lend support to the applicability of the expectation-outcomediscrepancy model of patient satisfaction in the context of day-stay cataractsurgery. Importantly, the improvement in visual function experienced by apatient did not at all significantly correlate with overall satisfaction,a finding that runs counter to common expectations. However, expected improvement,actual outcome, and expectation-outcome discrepancy were all moderately correlatedwith satisfaction. Clearly, patient satisfaction is a complex and multidimensionalconstruct that cannot be explained by a single variable.7,10,24 However,it is worth noting that when controlling for other factors, neither actualimprovement nor actual outcome were predictive of patient satisfaction, whilethe expectation-outcome discrepancy was.

These findings further reinforce the only previous study to formallydocument patient expectations,40 demonstratingthat patient expectations are unreasonably high and few patients realisticallyachieve them. In short, 70-year-old patients expect cataract surgery to allowthem to see like 20-year-olds, although at this age there are inevitably otherfactors beside cataract that will impair their vision to some degree. It isnot surprising that ocular comorbidity is a major predictor of patient dissatisfactionwith cataract surgery.41,42

As with the previous study, reading small print, doing fine handiwork,and reading a newspaper were the most likely areas of high expectations forimprovement (as well as disappointment with outcome). For our sample, drivingat night was also a source of unrealistic and unfulfilled expectations forthe 34 patients (24%) who did so.

Patients’ perceived level of understanding at 1 month was stronglycorrelated with satisfaction. Some part of this correlation may be owing toan overarching response bias toward visual analog scales presented at thesame sitting, despite the fact that the questions were presented as clearlyindependent and visual analog scales have been shown to be both reliable andvalid measures in similar contexts.43,44 Additionally,the correlation between perceived understanding and satisfaction suppliesno evidence as to the direction of causation. Nonetheless, it is likely thatperceived understanding, as with expectation-outcome discrepancy, is an importantcomponent of patient satisfaction.

Although the strength of correlations was modest, explaining just 4%to 17% of the variance (r2), they werestrongly significant and consistent in magnitude with other studies of satisfaction,the determination of which is highly multifactorial. We must also acknowledgethat the difference between interviewer-assisted preoperative and self-administeredpostoperative questionnaires may affect the scores obtained, although thisdifference was consistent across all patients and should not affect the findingsof this study. Furthermore, the VF-14 in particular has been extensively validatedand found to be both stable and reliable across a wide range of contexts.38,39 This study did not investigate thechanging trajectory of patient expectations across time prior to surgery,nor the impact on satisfaction on the tiny minority who experienced operativecomplications. Further research into these subsidiary questions could providea more nuanced view of the relationship between expectations, outcome, andsatisfaction.

To provide the highest level of satisfaction, health care professionalsmust control their patients’ expectations and understanding of treatment,11 and the close relationship between accurate patientexpectations and adequate informed consent cannot be ignored.40 Infact, to improve patient satisfaction, health care professionals would beadvised to pay more attention to patient understanding and expectations, evenat the expense of improving patient outcome. In this study, the degree ofimprovement in visual function was not significantly correlated with patientsatisfaction at all.

This study highlights the particular areas where greater attention toinforming patients’ preoperative expectations would be warranted, aswell as important rationales for doing so. Finally, this study strongly supportsthe proposition that perceived patient understanding and expectation-outcomediscrepancy are important factors in overall patient satisfaction.

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Article Information

Correspondence: Chet K. Pager, BMed (Hons),DipEd, MA, 67 Missenden Rd PO, Royal Prince Albert Hospital, Camperdown NSW2050, Australia (ckpager@stanfordalumni.org).

Financial Disclosure: None.

Submitted for Publication: October 1, 2003;final revision received March 29, 2004; accepted June 29, 2004.

Funding/Support: This study was supported inpart by the National Health and Medical Research Council of Australia, Canberra.

References
1.
Scott  ASmith  RD Keeping the customer satisfied: issues in the interpretation and useof patient satisfaction surveys. Int J Qual Health Care 1994;6353- 359
PubMedArticle
2.
Epstein  AM The outcomes movement: will it get us where we want to go? N Engl J Med 1990;323266- 270
PubMedArticle
3.
Feinstein  ARJosephy  BRWells  CK Scientific and clinical problems in indexes of functional disability. Ann Intern Med 1986;105413- 420
PubMedArticle
4.
Cleary  PDMcNeil  BJ Patient satisfaction as an indicator of quality of care. Inquiry 1988;2525- 36
PubMed
5.
Fitzpatrick  R Survey of patient satisfaction, I: important general considerations. BMJ 1991;302887- 889
PubMedArticle
6.
Donabedian  A The quality of care: how can it be assessed? JAMA 1988;2601743- 1748
PubMedArticle
7.
Aharony  LStrasser  S Patient satisfaction: what we know about and what we still need toexplore. Med Care Rev 1993;5049- 79
PubMedArticle
8.
Padberg  RMPadberg  LF Strengthening the effectiveness of patient education: applied principlesof adult education. Oncol Nurs Forum 1990;1765- 69
PubMed
9.
Hall  JADornan  MC Meta-analysis of satisfaction with medical care: description of researchdomain and analysis of overall satisfaction levels. Soc Sci Med 1988;27637- 644
PubMedArticle
10.
Williams  B Patient satisfaction: a valid concept? Soc Sci Med 1994;38509- 516
PubMedArticle
11.
Yucelt  U An investigation of causes of patient satisfaction/dissatisfactionwith physician services. Health Mark Q 1994;1211- 28
PubMedArticle
12.
Angelopoulou  PKangis  PBabis  G Private and public medicine: a comparison of quality perceptions. Int J Health Care Qual Assur Inc Leadersh Health Serv 1998;1114- 20
PubMedArticle
13.
Ware  JEDavies  AR Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann 1983;6291- 297
PubMedArticle
14.
Rubin  HRGandek  BRogers  WHKosinski  MMcHorney  CAWare  JE Patients' ratings of outpatient visits in different practice settings:results from the Medical Outcomes Study. JAMA 1993;270835- 840
PubMedArticle
15.
Rubin  HR Can patients evaluate the quality of hospital care? Med Care Rev 1990;47267- 326
PubMedArticle
16.
Zeithaml  VAParasuraman  ABerry  LL Delivering Quality Service: Balancing Customer Perceptionsand Expectations.  New York, NY T Free Press1990;
17.
Messner  RLLewis  SJ Increasing Patient Satisfaction: A Guide for Nurses.  New York, NY Springer1996;
18.
Carr-Hill  RA The measurement of patient satisfaction. J Public Health Med 1992;14236- 249
PubMed
19.
Thompson  AGSunol  R Expectations as determinants of patient satisfaction: concepts, theoryand evidence. Int J Qual Health Care 1995;7127- 141
PubMed
20.
Flood  ABLorence  DPDing  JMcPherson  KBlack  NA The role of expectations in patients' reports of post-operativeoutcomes and improvement following therapy. Med Care 1993;311043- 1056
PubMedArticle
21.
Fitzpatrick  RHopkins  A Problems in the conceptual framework of patient satisfaction research:an empirical exploration. Sociol Health Illn 1983;5297- 311
PubMedArticle
22.
Draper  MHill  S The Role of Patient Satisfaction Surveys in a NationalApproach to Hospital Quality Management.  Melbourne Australian Government Publishing Service1995;
23.
Linder-Pelz  S Toward a theory of patient satisfaction. Soc Sci Med 1982;16577- 582
PubMedArticle
24.
Linder-Pelz  S Social psychological determinants of patient satisfaction: a test offive hypotheses. Soc Sci Med 1982;16583- 589
PubMedArticle
25.
Egbert  LDBattit  GEWelch  CE  et al.  Reeducation of post-operative pain: encouragement and instruction topatients. N Engl J Med 1964;270825- 827
PubMedArticle
26.
Taylor  HR Cataract: how much surgery do we have to do? Br J Ophthalmol 2000;841- 2
PubMedArticle
27.
Westcott  MCTuft  SJMinassian  DC Effect of age on visual outcome following cataract extraction. Br J Ophthalmol 2000;841380- 1382
PubMedArticle
28.
American Academy of Ophthalmology, Preferred Practice Pattern: Cataract in the AdultEye.  San Francisco Calif American Academy of Ophthalmology2001;8
29.
McCarty  CAKeeffe  JETaylor  HR The need for cataract surgery: projections based on lens opacity, visualacuity, and personal concern. Br J Ophthalmol 1999;8362- 65
PubMedArticle
30.
World Health Organization, Global Initiative for the Elimination of AvoidableBlindness: An Informal Consultation.  Geneva, Switzerland World Health Organization1997;WHO/PBL/97.61
31.
Keeffe  JETaylor  HR Cataract surgery in Australia 1985-94. Aust N Z J Ophthalmol 1996;24313- 317
PubMedArticle
32.
Batterbury  MKhaw  PTHands  R  et al.  The cataract explosion: the changing pattern of diagnoses of patientsattending an ophthalmic outpatient department. Eye 1991;5369- 372
PubMedArticle
33.
Friedman  DSSchein  OD Assessing disability in the patient with cataract. Curr Opin Ophthalmol 1998;91- 4
PubMedArticle
34.
Legro  MW Quality of life and cataracts: a review of patient-centered studiesof cataract surgery outcomes. Ophthalmic Surg 1991;22431- 443
PubMed
35.
McCarty  CANanjan  MBTaylor  HR Operated and unoperated cataract in Australia. Clin Experiment Ophthalmol 2000;2877- 82
PubMedArticle
36.
Keeffe  JEMcCarty  CAChang  WPSteinberg  EPTaylor  HR Relative importance of visual acuity, patient concern and patient lifestyleon referral for cataract surgery [ARVO abstract 871]. Invest Ophthalmol Vis Sci 1996;37S183
37.
Mangione  CMPhillips  RSLawrence  MG  et al.  Improved visual function and attenuation of declines in health-relatedquality of life after cataract extraction. Arch Ophthalmol 1994;1121419- 1425
PubMedArticle
38.
Alonso  JEspallargues  MAndersen  TF  et al.  International applicability of the VF-14: an index of visual functionin patients with cataracts. Ophthalmology 1997;104799- 807
PubMedArticle
39.
Cassard  SDPatrick  DLDamiano  AM  et al.  Reproducibility and responsiveness of the VF-14: an index of functionalimpairment in patients with cataracts. Arch Ophthalmol 1995;1131508- 1513
PubMedArticle
40.
Tielsch  JMSteinberg  EPCassard  SD  et al.  Preoperative functional expectations and postoperative outcomes amongpatients undergoing first eye cataract surgery. Arch Ophthalmol 1995;1131312- 1318
PubMedArticle
41.
Lundstrom  MBarry  PLeite  ESeward  H  et al.  1998 European Cataract Outcome Study: report from the European CataractOutcome Study Group. J Cataract Refract Surg 2001;271176- 1184
PubMedArticle
42.
Chang-Godinich  AOur  RJKoch  DD Functional improvement after phacoemulsification cataract surgery. J Cataract Refract Surg 1999;251226- 1231
PubMedArticle
43.
Capodaglio  EM Comparison between the CR10 Borg's scale and the VAS (visual analoguescale) during an arm-cranking exercise. J Occup Rehabil 2001;1169- 74
PubMedArticle
44.
Bernth-Petersen  P Visual functioning in cataract patients: methods of measuring and results. Acta Ophthalmol (Copenh) 1981;59198- 205
PubMedArticle
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