Introduction: This is the first study examining patient expectations about care delivered by urologists, for uncomplicated male LUTS.
About 60-70% of all men with LUTS seek help from a general practitioner (GP) (1). If the treatment provided by the GP – mostly alpha-blockers – is not effective, patients are referred to a urologist. Urologists have a multitude of treatment options available. In the context of patient centered care it is important to know what patients expect from the urologist. Also, expectations relate to treatment outcome and satisfaction (2). However, this has never been studied in this particular patient group. We hypothesized that patient satisfaction is higher if treatment choices are congruent with patient expectations.
Aim: To investigate the expectations of male patients with uncomplicated LUTS in their consultation with/ the treatment of the urologist. Next, we aimed to study the association between patient satisfaction with patient expectations.

Study design: Prospective cohort study.
Materials and methods: Male patients with uncomplicated LUTS older than 18 years referred to the urologist for the first time, in 3 different hospitals, were asked to participate. Men were excluded if they had 1) bladder or prostate cancer, 2) indication for acute intervention (e.g. urinary retention), 3) neurogenic bladder, 4) urethral stricture, 5) severe co-morbidity, or 6) were unable to understand Dutch. 
Each participant was asked to sign informed consent, and fill out a questionnaire before the first consultation with the urologist, and after six weeks. At baseline, the questionnaire consisted of questions about the expectations of the patients on secondary care (5 point Likert scale), symptom severity using the IPSS and OAB-q, and patient characteristics. The questionnaire at 6 weeks consisted of which treatment the urologist started, if the treatment was consistent with the expectations (5 point Likert scale), satisfaction with the care of the urologist (5 point Likert scale), and the IPSS. Primary outcome measures are the expectations of the patients. Secondary outcome measures were treatment satisfaction, and association between expectations and chosen therapy. IBM SPSS version 25 was used for the analyses.

Results: Preliminary analyses included data from 173 men with uncomplicated LUTS who agreed to participate in this study (response rate 54%). Patients’ expectations with care, treatment plan and treatment outcomes are provided in Table 1.
Considering expectations of care, above 80% of the participants responded that it is likely or very likely that the urologist would perform examinations, provide an explanation about the cause of the symptoms, find the underlying cause of the symptoms, and that the patient himself is involved in the forming of the treatment plan. 
For the treatment plan, about 50% of the participants expected lifestyle advice, 40% expected medication, only 20% expected an operation and just 12% expected physiotherapy as a treatment for their symptoms. However, the largest group (about 45%) for every treatment option, except lifestyle advice, scored neutral. 
For treatment outcomes, reduction of symptoms was likely or very likely expected by 20% for lifestyle advice, by 43% for medication, and 30% for an operation. Only 7% of all men found it likely or very likely that physiotherapy would reduce symptoms. Twenty-two percent of the participants expected adverse effects from an operation, compared to 27% for medication. 
Of the 133 participants that filled in the second questionnaire (data is still being collected), 71% was satisfied with the treatment of the urologist and 68% said that the treatment corresponded with their expectations (‘self-reported agreement’) (table 2). However, if the received treatment was checked against the expectation of that treatment for each participant, a match was shown in just 28% of the participants (‘objective agreement’). Patients are significantly more satisfied with the treatment at six weeks if they report that the treatment corresponds with their expectations (median = 4) compared to patients that do not report a correspondence (median = 3) (self-reported agreement; Mann-Whitney U-test: p < 0,001). However, there is no significant difference in satisfaction at 6 weeks between men with (median = 4) and without (median = 4) objective agreement (Mann-Whitney U-test: p = 0,559).

Interpretation of the results: We found that about 45% of the participants had a neutral expectation for each treatment option. This could mean that men referred to secondary care had no explicit expectations about which diagnostics and treatment the urologist would apply. Possible explanations were not explored in this study, but could include limited information provided by the referring GP, or provided by the hospitals in advance of the first outpatient department visit.
We noticed a strong discrepancy between self-reported and objective agreement between patient expectations about treatment and treatment choice. That is, after 6 weeks 67% of the participants reported that the treatment corresponded with their expectations. However, the actual received treatment matched with their expectations in just 28% of the participants. The large group of men with neutral expectations about treatment options could explain this. This may result in a more positive attitude to whichever treatment they received, and the conception that expectations were met. Another explanation could be that patients did not only consider the given treatment when answering the question, but also took into consideration the whole experience of the consultation with the urologist.
As hypothesized, we found that participants are more satisfied with the treatment if the treatment is congruent with their expectations. This is comparable with research done in other fields (3). Notably, this association was only found for self-reported agreement between expectations and chosen treatment. We found no association between patient satisfaction and objective agreement.

Concluding message: The vast majority of men with uncomplicated LUTS referred to secondary care expected that the urologist would perform diagnostics, and find the underlying cause of their symptoms. 
There is a strong discrepancy between self-reported and objective agreement between patient expectations and chosen treatment. Patient satisfaction about the provided care is strongly associated with self-reported agreement, but not objective agreement.

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Ross CK, Frommelt G, Hazelwood L, Chang RW. The role of expectations in patient satisfaction with medical care. J Health Care Mark 1987 Dec;7(4):16-26.
Jain D, Nguyen LL, Bendich I, Nguyen LL, Lewis CG, Huddleston JI, et al. Higher Patient Expectations Predict Higher Patient-Reported Outcomes, But Not Satisfaction, in Total Knee Arthroplasty Patients: A Prospective Multicenter Study. J Arthroplasty 2017 Sep;32(9S):S166-S170.