Surgeons’ preoperative expectations were more accurate than patients’ expectations in predicting patient-reported outcomes 2 years after lumbar spine surgery, according to a longitudinal study by investigators at Hospital for Special Surgery (HSS), published in Spine.

Most patients had higher expectations than their surgeons did, with many anticipating complete improvement after seeking additional information beyond that provided by their surgeons, according to a media release from Hospital for Special Surgery.

“There have been tremendous advances in spine surgery over the past 20 years, including minimally invasive and robotic approaches, new implants and bone grafting methods.

“However, despite clinical assessment and improvements seen on postoperative imaging, some patients report they are not doing well compared to others with similar conditions who received the same surgeries. That has been very frustrating for surgeons because our goal is to optimize patient outcomes.”

— Federico P. Girardi, MD, an attending orthopaedic surgeon at HSS

“Patients decide to pursue lumbar spine surgery to relieve symptoms, improve their quality of life and avoid further disability.

“Unrealistically high or low expectations are problematic, predisposing patients to poor outcomes if they become discouraged with recovery, abandon rehabilitation or ignore recommended lifestyle modifications that reduce disease progression.”

— Carol A. Mancuso, MD, FACP, a general internist and clinical epidemiologist at HSS

Survey Aims to Understand the Gap

To understand the gap between expectations and patient-reported outcomes, Girardi, Mancuso and colleagues developed the HSS Lumbar Spine Surgery Expectations Survey in 2013 with input from hundreds of patients on the surgical outcome factors that matter most to them. The comprehensive, validated tool evaluates patients’ expectations for symptom relief, resuming activities, and importantly, psychological well-being, which previous surgeon-oriented surveys did not capture.

In their study, Girardi, Mancuso and colleagues asked 402 patients and their surgeons to preoperatively assess their expectations of patient-reported surgical outcomes using the HSS Lumbar Spine Surgery Expectations Survey. The researchers surveyed patients again, 2 years after surgery, to evaluate the degree of fulfillment of their expectations.

Patients participating in the study were 55 years of age, on average. Most had a degenerative spine condition and had experienced symptoms for a year or longer. About one-quarter had undergone previous spine surgery, and one-third were taking opioids to relieve leg and back pain.

The extent of surgical procedures spanned from the removal of a single, herniated disc to more complex operations such as a five-level anterior-posterior decompression, instrumentation and fusion.

Responses to the HSS Lumbar Spine Surgery Expectations Survey generate a score on a scale of 0 to 100, where a higher score indicates higher expectations. Patients’ average preoperative score in the study was 73 (ranging from 20 to 100), much higher than surgeons’ average score of 57 (ranging from 16 to 100).

Were The Expectations Fulfilled?

Next, the investigators determined whether surgeons or patients’ presurgical expectations more closely predicted postoperative fulfillment of those expectations as reported by patients. The proportion of expectations fulfilled was .79 for patients, indicating that they were satisfied overall.

Mancuso’s previous research found that a ratio of .6 or higher corresponds with satisfaction with surgical results. However, the surgeons’ ratio was 1.01, meaning that their predictions for patient-reported outcomes were highly accurate and more accurate than patients’ presurgical estimates. In 73% of cases, surgeons either predicted patients’ reported outcomes exactly, or patients surpassed surgeons’ expectations.

“HSS spine surgeons very accurately predicted patient-reported outcomes 2 years after surgery, indicating that they are adept at integrating complex clinical, surgical and psychological factors that matter most to patients.

“Getting this right is an indicator of providing high-quality and high-value care.”

— Carol A. Mancuso, MD, FACP

Overall, surgeons and patients agreed on the same areas of improvement. However, expectations for the degree of improvement differed. Surgeons expected surgery would lead to a little, moderate, or a lot of improvement, based on their clinical expertise treating hundreds of patients. However, 84% of patients had higher expectations than their surgeons, often expecting complete improvement.

The investigators interviewed patients about the source of their expectations and discovered they had amplified their surgeons’ guidance with information they obtained from family, friends, coworkers and the internet.

“Our study underscores that there is room for improvement in patient education and that patients should rely on their surgeon’s expertise when forming expectations of lumbar spine surgery.

“At HSS, we recognize that expectations for surgical outcomes are affected by many factors and develop evidence-based, individualized treatment plans. Patients need to realize that anecdotal stories from social contacts or the internet are often not relevant to their situation.”

— Federico P. Girardi, MD

[Source(s): Hospital for Special Surgery, EurekAlert]

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