Discrepancies Between Patient and Surgeon Expectations of Surgery for Sciatica: A Challenge for Informed Decision Making?

Experiences and perceptions of adults pre- and/or post-lumbar spine surgery: a meta-ethnography

STUDY DESIGN

Qualitative meta-ethnography. Pre-registered with OSF:10.17605/OSF.IO/UTZE6.

PURPOSE

To understand the patient experience pre- and/or post-lumbar spine surgery.

METHODS

Literature search: A literature search was conducted in MEDLINE, EMBASE, EmCare and CINAHL from inception to October 17, 2022. Study selection criteria: Peer-reviewed qualitative or mixed-method studies of English text investigating the beliefs, perceptions, or experiences of adults (≥18 years old) pre- and/or post-lumbar spine surgery for degenerative, non-traumatic or non-infectious concerns. Data synthesis: The eMERGE meta-ethnography reporting guidelines were followed to create themes and subthemes from the original themes of the included studies. A quality appraisal was performed using the McMaster Quality Appraisal tool.

RESULTS

We included 18 studies and identified five themes that were separated into pre- and post-operative categories. The two pre-operative themes included [1]: the influence of physiotherapy interventions on patients' experiences, and [2] the importance of education/the power of communication, and the three post-operative themes included [1]: psychosocial coping [2], redefining oneself post-operatively, and [3] experience with the healthcare system.

CONCLUSIONS

These findings emphasize the complexity of the peri-operative experience for individuals undergoing lumbar spine surgery. Future research should focus on addressing psychosocial factors that may optimize patient experiences and recovery following LSS.

Understanding How Patients With Lumbar Radiculopathy Make Sense of and Cope With Their Symptoms

Lumbar radiculopathy, characterized by pain radiating along a nerve root, significantly diminishes the quality of life due to its neuropathic nature. Patients' understanding of their illness and the coping strategies they employ directly influence how they manage their condition. Understanding these illness representations from the patient's perspective is crucial for healthcare providers seeking to optimize treatment outcomes. This study adopted a qualitative interpretive/constructive paradigm to explore this dynamic. A qualitative evidence synthesis approach, utilizing best-fit framework synthesis for data extraction, was applied to analyze primary qualitative studies focused on patient experiences with lumbar radiculopathy. Using SPiDER (Sample, Phenomenon of interest, Design, Evaluation, Research type) to guide the search strategy, extracted data was mapped against the Common-Sense Model of Self-Regulation (CSM) framework. Sixteen studies, with moderate to minor methodological quality concerns, were included in the analysis. Data mapping across CSM domains generated 14 key review findings. Results suggest that patients with high-threat illness representations often exhibit maladaptive coping behaviors (e.g., activity avoidance) driven by emotional responses. In contrast, problem-solving techniques appear to contribute to positive outcomes (e.g., exercise adherence and effective self-management) in patients who perceive their condition as less threatening. These findings highlight the potential benefits of interventions designed to reduce perceived threat levels and enhance self-efficacy in patients with lumbar radiculopathy, leading to improved self-management and ultimately better health outcomes.

Measures of retention in HIV care: A protocol for a mixed methods study

INTRODUCTION

Retention in HIV care is necessary to achieve adherence to antiretroviral therapy, viral load suppression, and optimal health outcomes. There is no standard definition for retention in HIV care, which compromises consistent and reliable reporting and comparison of retention across facilities, jurisdictions, and studies.

OBJECTIVE

The objective of this study is to explore how stakeholders involved in HIV care define retention in HIV care and their preferences on measuring retention.

METHODS

We will use an exploratory sequential mixed methods design involving HIV stakeholder groups such as people living with HIV, people involved in providing care for PLHIV, and people involved in decision-making about PLHIV. In the qualitative phase of the study, we will conduct 20-25 in-depth interviews to collect the perspectives of HIV stakeholders on using their preferred retention measures. The findings from the qualitative phase will inform the development of survey items for the quantitative phase. Survey participants (n = 385) will be invited to rate the importance of each approach to measuring retention on a seven-point Likert scale. We will merge the qualitative and quantitative findings phase findings to inform a consensus-building framework for a standard definition of retention in care.

ETHICAL ISSUES AND DISSEMINATION

This study has received ethics approval from the Hamilton Integrated Research Ethics Board. The findings will be disseminated through peer-reviewed publications, conference presentations, and among stakeholder groups.

LIMITATIONS

This study has limitations; we won't be able to arrive at a standard definition; a Delphi technique amongst the stakeholders will be utilized using the framework to reach a consensus globally accepted definition.

Would You Do It Again? Discrepancies Between Patient and Surgeon Perceptions Following Adult Spine Deformity Surgery

BACKGROUND

Adult spinal deformity (ASD) surgery can improve patient pain and physical function but is associated with high complication rates and long postoperative recovery. Accordingly, if given a choice, patients may indicate they would not undergo ASD surgery again.

PURPOSE

Evaluate surgically treated ASD patients to assess if given the option 1) would surgically treated ASD patients choose to undergo the same ASD surgery again, 2) would the treating surgeon perform the same ASD surgery again and if not why, 3) evaluate for consensus and/or discrepancies between patient and surgeon opinions for willingness to perform/receive the same surgery, and 4) evaluate for associations with willingness to undergo or not undergo the same surgery again and patient demographics, patient reported outcomes, and postoperative complications.

STUDY DESIGN

Retrospective review of a prospective ASD study.

PATIENT SAMPLE

Surgically treated ASD patients enrolled into a multicenter prospective study.

OUTCOME MEASURES

Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36) physical component summary (PCS) and mental component summary (MCS), Oswestry Disability Index (ODI), numeric pain rating for back pain (NRS back) and leg pain (NRS leg), minimal clinically important difference (MCID) for SRS-22r domains and ODI, intraoperative and postoperative complications, surgeon and patient satisfaction with surgery.

METHODS

Surgically treated ASD patients prospectively enrolled into a multicenter study were asked at minimum two year postoperative, if, based upon their hospital and surgical experiences and surgical recovery experiences, would the patient undergo the same surgery again. Treating surgeons were then matched to their corresponding patients, blinded to the patients' preoperative and postoperative patient reported outcome measures, and interviewed and asked if 1) the surgeon believed that the corresponding patient would undergo the surgery again, 2) if the surgeon believed the corresponding patient was improved by the surgery and 3) if the surgeon would perform the same surgery on the corresponding patient again, and if not why. ASD patients were divided into those indicating they would (YES), would not (NO) or were unsure (UNSURE) if they would have same surgery again. Agreement between patient and surgeon willingness to receive/perform the same surgery was assessed and correlations between patient willingness for same surgery, postoperative complications, spine deformity correction, patient reported outcomes (PROs).

RESULTS

580 of 961 ASD patients eligible for study were evaluated. YES (n=472) had similar surgical procedures performed, similar duration of hospital and ICU stay, similar spine deformity correction and similar postoperative spinal alignment as NO (n=29; p>0.05). UNSURE (n=79) had greater preoperative depression and opioid use rates, UNSURE and NO had more postoperative complications requiring surgery, and UNSURE and NO had fewer percentages of patients reaching postoperative MCID for SRS-22r domains and MCID for ODI than YES (p<0.05). Comparison of patient willingness to receive the same surgery vs. surgeon perceptions on patient's willingness to receive the same surgery demonstrated surgeons accurately identified YES (91.1%) but poorly identified NO (13.8%; p<0.05).

CONCLUSIONS

If given a choice, 18.6% of surgically treated ASD patients indicated they were unsure or would not undergo the surgery again. ASD patients indicating they were unsure or would not undergo ASD surgery again had greater preoperative depression, greater preoperative opioid use, worse postoperative PROs, fewer patients reaching MCID, more complications requiring surgery, and greater postoperative opioid use. Additionally, patients that indicated they would not have the same surgery again were poorly identified by their treating surgeons compared to patients indicating they would be willing to receive the same surgery again. More research is needed to understand patient expectations and improve patient experiences following ASD surgery.

Surgical Informed Consent: A Scoping Review of Physician-facing Decision Support Tools

Objectives

Physician-facing decision support tools facilitate shared decision-making (SDM) during informed consent, but it is unclear whether they are comprehensive in the domains they measure. In this scoping review, we aimed to (1) identify the physician-facing tools used during SDM; (2) assess the patient-centered domains measured by these tools; (3) determine whether tools are available for older adults and for use in various settings (elective vs. emergent); and (4) characterize domains future tools should measure.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews, Embase, Medline, and Web of Science were queried for articles published between January 2000 and September 2022. Articles meeting inclusion criteria underwent title and abstract review. Eligible studies underwent data abstraction by two reviewers.

Results

Of 4365 articles identified, 160 were eligible. Tools to aid in surgical SDM focus on elective procedures (79%) and the outpatient setting (71%). Few tools are designed for older adults (5%) or for nonelective procedures (9%). Risk calculators were most common, followed by risk indices, prognostic nomograms, and communication tools. Of the domains measured, prognosis was more commonly measured (85%), followed by alternatives (28%), patient goals (36%), and expectations (46%). Most tools represented only one domain (prognosis, 33.1%) and only 6.7% represented all four domains.

Conclusions and Implications

Tools to aid in the surgical SDM process measure short-term prognosis more often than patient-centered domains such as long-term prognosis, patient goals, and expectations. Further research should focus on communication tools, the needs of older patients, and use in diverse settings.

Patient Expectations About Palliative Treatment for Symptomatic Spinal Metastases: A Qualitative Study

OBJECTIVES

Patients with spinal metastases often receive palliative surgery or radiation therapy to maintain or improve health-related quality of life. Patients with unrealistic expectations regarding treatment outcomes have been shown to be less satisfied with their post-treatment health status. This study evaluated expectations of patients with spinal metastases scheduled for surgery and/or radiation therapy.

METHODS

Individual semistructured interviews were conducted with patients with symptomatic spinal metastases before and 6 weeks after surgery and/or radiation therapy. Expectations regarding treatment outcomes were discussed before treatment, and level of fulfillment of these pretreatment expectations was discussed after treatment. Interviews were recorded, transcribed and analyzed according to the thematic analysis method to identify themes.

RESULTS

Before treatment, patients thought they were not, or minimally, informed about (expected) treatment outcomes, but they felt well informed about treatment procedures and possible complications. Although patients expected pain relief and improvement in daily functioning, they found it difficult to describe any recovery timeline or the impact of these expected improvements on their daily life. Patients generally understood that treatment was not curative, but lacked insight into the impact of treatment on life expectancy given that this was hardly discussed by their surgeon and/or radiation oncologist. Pretreatment expectations regarding pain and daily functioning were only partially met in most patients post-treatment.

CONCLUSIONS

Patients thought they were not, or only minimally, informed about expected outcomes after surgery and/or radiation therapy for symptomatic spinal metastases. Improvements in patient-physician communication and counseling could help guide patients toward realistic pretreatment expectations.

Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study

Background

Clinical guidelines recommend engaging patients in shared decision making for common orthopedic procedures; however, limited work has assessed what is occurring in practice. This study assessed the quality of shared decision making for elective hip and knee replacement and spine surgery at four network-affiliated hospitals.

Methods

A cross-sectional sample of 875 adult patients undergoing total hip or knee joint replacement (TJR) for osteoarthritis or spine surgery for lumbar herniated disc or lumbar spinal stenosis was selected. Patients were mailed a survey including measures of Shared Decision Making (SDMP scale) and Informed, Patient-Centered (IPC) decisions. We examined decision-making across sites, surgeons, and conditions, and whether the decision-making measures were associated with better health outcomes. Analyses were adjusted for clustering of patients within surgeons.

Results

Six hundred forty-six surveys (74% response rate) were returned with sufficient responses for analysis. Patients who had TJR reported lower SDMP scores than patients who had spine surgery (2.2 vs. 2.8; p < 0.001). Patients who had TJR were more likely to make IPC decisions (OA = 70%, Spine = 41%; p < 0.001). SDMP and IPC scores varied widely across surgeons, but the site was not predictive of SDMP scores or IPC decisions (all p > 0.09). Higher SDMP scores and IPC decisions were associated with larger improvements in global health outcomes for patients who had TJR, but not patients who had spine surgery.

Conclusions

Measures of shared decision making and decision quality varied among patients undergoing common elective orthopedic procedures. Routine measurement of shared decision making provides insight into areas of strength across these different orthopedic conditions as well as areas in need of improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04853-x.

The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study

OBJECTIVE

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients.

METHODS

Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected.

RESULTS

There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34-0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not.

CONCLUSIONS

Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

Managing shoulder pain: a meta-ethnography exploring healthcare providers' experiences

OBJECTIVE

To review and synthesize qualitative research studies exploring the experiences of Healthcare Providers (HCPs) of managing shoulder pain.

METHODS

A meta-ethnographic approach was adopted to review and synthesize eligible studies. The findings from each included study were translated into one another using Noblit and Hares' seven-stage process. A systematic search of eleven electronic databases was conducted in February 2021. Methodological quality was assessed using the CASP Appraisal Tool.

RESULTS

Ten studies were included in the meta-synthesis, all deemed of high methodological quality. Three themes were identified; (1) Lack of consensus: "we all have different approaches." (2) Challenges to Changing Practice: It's "really hard to change and switch to a different approach," (3) Getting "Buy in" to Treatment: "…so you have to really sell it early".

CONCLUSION

Healthcare providers working with people with shoulder pain struggle to reconcile, often conflicting, research recommendations with their own clinical experience, beliefs and patient expectations. These findings help explain the continued lack of consensus on how best to manage shoulder pain in clinical practice.IMPLICATIONS FOR REHABILITATIONHealthcare providers (HCPs) working with people with shoulder pain struggle to resolve conflicts between evidence-based recommendations, clinical experience, their own shoulder pain beliefs and patient expectations and preferences.Stronger collaboration across professional disciplines is needed to address the current lack of consensus on the management of shoulder pain.Many HCP's find it difficult to engage patients with shoulder pain in exercise and they work hard to "sell" this approach to patients using strategies such as education, shared decision making and therapeutic alliance.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies

Background

Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care.

Methods

A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality.

Results

The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates.

Conclusions

Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes.

Trial registration

PROSPERO registration number: CRD42020145151.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07683-7.