Recall of potential deformity surgery complications declines over time

One year postoperatively, patients recalled 20% of the informed consent discussion.

A recent study found that adult patients who undergo spinal deformity surgery have poor recall of potential complications, despite receiving a standard surgeon-initiated informed consent discussion and watching a 20-minute video detailing several potential complications.

According to a presentation of the findings by Christopher P. Ames, MD, of San Francisco, patients who underwent adult deformity surgery recalled fewer than 50% of the risks discussed in the informed consent process preoperatively and the recall rate declined significantly in the postoperative period.

“So, despite a standard informed consent process, we see a preoperative recall and immediate recall of the risks at 40%,” he said

The complication rates in this type of procedure are high — up to 60% — based on the study, therefore it is important for patients to have a clear understanding of the potential complications and risks, Ames said.

Recall and legal cases

“To complicate matters even further, we have a challenging legal medical environment in the United States. Many medical legal cases involved specifically informed consent issues,” Ames said.

At 1 year postoperatively, patients recalled about 20% of the informed consent discussion. It is at 1 year after surgery that most medical legal cases are filed, he said.

Ames and colleagues enrolled 30 patients in the study with a median age of 60.5 years; 16% of them were women, based on the study. All cases took place in 2012. In the preoperative clinic, patients underwent a surgeon-initiated informed consent discussion and they watched a 20-minute video that detailed 11 complications related to the procedure.

Complications recalled

The patients were given a quiz that assessed their ability to recall the 11 complications, a numerical scale for both the commonality and severity of each complication (0 being minor and 10 being very severe) and a 16-point mini-mental status exam. All of these factors were recorded preoperatively, at hospital discharge and at 6 weeks, 3 months and 6 months postoperatively.

At the preoperative visit, patients underwent a standard informed consent. “This did not interfere at all with the standard physician patient relationship in informed consent process, but then in addition to that, the patients all watched an objective 20 minute video with very detailed descriptions of the complications in adult deformity surgery and then they were assessed with a mental status test,” Ames said. Afterward they were asked to recall the 11 complications and to rank the complications for severity. Then they were asked to rank the relative commonality of those complications in adult deformity, he said.

Recall declined at postop

According to the study, patients showed an immediate preoperative recall of the risks and complications at 41% accuracy. However, the results began to significantly decline after surgery, Ames noted.

“[The recall] deteriorates to really just a little bit more than 20% at 6 months, and at 1 year, the point at which most lawsuits are filed, we see again about a 20% recall rate of the informed consent discussion,” he said in the presentation. “This is with the standard informed consent, the video consent and then supplying these patients with a take home list of the complications.”

None of the patients displayed a mental status deterioration over the 1 year course of time, he said.

Additionally, Ames and colleagues found the perception of severity of complications significantly differed between patient and surgeons.

“They (patients) assessed the most severe complication they could experience as bleeding requiring transfusion. They assessed the least severe as blindness,” Ames said. “This must indicate some type of integration of the frequency versus the severity, but again they were asked these questions separately. Death was given a median of 4.5, less severe than bleeding requiring transfusion.”

Further research is needed to optimize the standard informed consent process, possibly with augmented video and targeted informed consent around the patient’s educational or mental status testing, the investigators noted. – by Robert Linnehan

Reference:

Ames CP. Paper #51. Presented at: North American Spine Society Annual Meeting; Oct. 9-12, 2013; New Orleans.

For more information:

Christopher P. Ames, MD, can be reached at University of California, San Francisco, Department of Neurological Surgery, 505 Parnassus Ave. Room M779, San Francisco, CA 94143; email: priesterk@neurosurg.ucsf.edu.
Disclosure: Ames or his institution receives royalties from Aesculap, Stryker, Lanx; he has stock in Trans1, Doctors Research Group and Visualase; and he consults with Medtronic, DePuy and Stryker.