Expected outcomes after lumbar spine surgery more accurate among surgeons vs patients
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Surgeons had more accurate preoperative expectations in predicting patient-reported outcomes 2 years after lumbar spine surgery compared with patients, who tended to have higher expectations.
Carol A. Mancuso, MD, senior scientist at Hospital for Special Surgery and professor of medicine at Weill Cornell Medical College, and colleagues provided identical surveys measuring expectations for improvement in symptoms and physical/psychosocial function to patients undergoing lumbar surgery and their surgeons.
“The survey can be scored to compile the amount of improvement expected and the score can range from zero to 100, with zero representing the least expectations and 100 representing the most expectations,” Mancuso told Healio Orthopedics.
Researchers used the intraclass correlation coefficient to measure concordance between patient and surgeon scores and measured postoperative patient and surgeon fulfillment of expectations based on the amount of improvement received vs. the amount of improvement expected.
Preoperative expectations
Among the 402 patient-surgeon pairs, researchers found mean survey scores of approximately 73 for patients and 57 for surgeons, with 84% of patients reporting higher scores than surgeons.
“What was interesting is that the difference in score was not due to differences in what was expected, but instead was due to differences in how much improvement was expected,” Mancuso said. “Whereas patients many times would say they expected complete improvement back to normal, surgeons, on the other hand, would say they expected a lot of improvement or a moderate amount of improvement.”
Intraclass correlation coefficient showed the entire sample had fair agreement, with patient’s degree of disability and functional limitations associated with lower expectations among surgeons vs. patients, according to Mancuso.
Additional sources of expectation
Researchers contacted 96% of patients 2 years after surgery and found patients over-estimated postoperative improvement and were less likely of meeting or surpassing expectations compared with surgeons.
“The surgeons were very successful in predicting what patients ultimately came to report was the outcome of their surgery,” Mancuso said. “That was important because it shows us that surgeons are able to integrate a complex scenario of physical function, psychological well-being, ... what is involved with the surgery, the diagnosis, the degree of disability ... and actually come up with a predicted amount of improvement that patients will actually receive.”
Although patients reported forming their expectations based on information from their surgeon, Mancuso said patients also listed relatives and friends, previous surgical experience and the internet as other sources for forming expectations.
“We need to be aware that patients get information about expectations from sources other than their surgeons,” Mancuso said. “We need to have potentially a catalogue or a place where we can refer patients to reinforce what the expectations that they received from their surgeons are [and] to provide them with better sources of expectations.”
Perspective
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Mancuso and colleagues reiterate important themes in patient-surgeon communication and informed consent. Even as studies increasingly examine patient reported outcomes for the impacts of care most meaningful to them (pain and function), effective preoperative communication about reasonable expectations for recovery and outcome remains challenging.
It was heartening to see that spine surgeons’ predictions of postoperative outcomes were relatively accurate and patients felt their surgeons had communicated those predictions to them. I find it helpful to describe practical goals of the surgery (reduce your pain and allow you to walk a mile) along with reasonable, postoperative rehabilitative milestones (by 6 weeks, you should be able to …). I also describe the range of functional outcomes we see and the patient specific factors that predict more or less recovery of function.
Yet, just as Mancuso and others report, patients use other sources for this information. In our center, we have graded the medical information offered online. The quality varied widely. Often, overly optimistic marketing language is used along with phrases like “fix your back.” These imply a return to some previous, youthful normalcy.
When counselling a patient about surgery, I typically offer reputable online resources that offer a reasonable accounting of the expected risks and benefits. With that said, it is clear we still have a way to go.
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