1
|
Karunaratne S, Harris IA, Horsley M, Trevena L, Solomon M. Second opinion in lower limb total joint arthroplasty: do surgeons agree on surgical management? ANZ J Surg 2024. [PMID: 38817144 DOI: 10.1111/ans.19113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian Andrew Harris
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Horsley
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Lyndal Trevena
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Debono B, Lonjon G, Guillain A, Moncany AH, Hamel O, Challier V, Diebo B. Spine surgeons facing second opinions: a qualitative study. Spine J 2024:S1529-9430(24)00155-4. [PMID: 38556219 DOI: 10.1016/j.spinee.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND CONTEXT The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. PURPOSE The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. STUDY DESIGN/SETTING This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. PATIENT SAMPLE We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). OUTCOME MEASURES Themes and subthemes were analyzed using semistructured interviews until saturation was reached. METHODS Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). RESULTS Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). CONCLUSIONS The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.
Collapse
Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, Santecite Group. St Jean de Vedas, Montpellier Metropole, France
| | - Antoine Guillain
- AMADES (Medical Anthropology, Development and Health), Centre de la Vieille Charité, Marseille, France
| | - Anne-Hélène Moncany
- Department of Psychiatry and Addictive Behaviour, Gerard Marchant Hospital Center, Toulouse, France
| | - Olivier Hamel
- Department of Neurosurgery, Ramsay Santé-Clinique des Cèdres, Cornebarrieu, France
| | - Vincent Challier
- Department of Orthopedic Surgery, Hôpital privé du dos Francheville, Périgueux, France
| | - Bassel Diebo
- Department of Orthopedic surgery, Brown University Warren Alpert Medical School, East Providence, RI, USA
| |
Collapse
|
3
|
Antonioli E, Tavares Malheiro D, Damazio Teich V, Dias Paião I, Cendoroglo Neto M, Lenza M. Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis. BMC Health Serv Res 2023; 23:1441. [PMID: 38115007 PMCID: PMC10731842 DOI: 10.1186/s12913-023-10405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND In this study we proposed a new strategy to measure cost-effectiveness of second opinion program on spine surgery, using as measure of effectiveness the minimal important change (MIC) in the quality of life reported by patients, including the satisfaction questionnaire regarding the treatment and direct medical costs. METHODS Retrospective analysis of patients with prior indication for spine surgery included in a second opinion program during May 2011 to May 2019. Treatment costs and outcomes were compared considering each patients' recommended treatment before and after the second opinion. Costs were measured under the perspective of the hospital, including hospital stay, surgical room, physician and staff fees and other costs related to hospitalization when surgery was performed and physiotherapy or injection costs when a conservative treatment was recommended. Reoperation costs were also included. For comparison analysis, we used data based on our clinical practice, using data from patients who underwent the same type of surgical procedure as recommended by the first referral. The measure of effectiveness was the percentage of patients who achieved the MIC in quality of life measured by the EQ-5D-3 L 2 years after starting treatment. An incremental cost-effectiveness ratio (ICER) was calculated. RESULTS Based upon the assessment of 1,088 patients that completed the entire second opinion process, conservative management was recommended for 662 (60.8%) patients; 49 (4.5%) were recommended to injection and 377 (34.7%) to surgery. Complex spine surgery, as arthrodesis, was recommended by second opinion in only 3.7% of cases. The program resulted in financial savings of -$6,705 per patient associated with appropriate treatment indication, with an incremental effectiveness of 0.077 patients achieving MIC when compared to the first referral, resulting in an ICER of $-87,066 per additional patient achieving the MIC, ranging between $-273,016 and $-41,832. CONCLUSION After 2 years of treatment, the second opinion program demonstrated the potential for cost-offsets associated with improved quality of life.
Collapse
Affiliation(s)
- Eliane Antonioli
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil.
| | - Daniel Tavares Malheiro
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil
| | - Vanessa Damazio Teich
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil
| | - Isabela Dias Paião
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil
| | - Miguel Cendoroglo Neto
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil
| | - Mario Lenza
- Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701 - Jardim Leonor - CEP, São Paulo, SP, 05652-900, Brazil
| |
Collapse
|
4
|
May S, Könsgen N, Glatt A, Bruch D, Muehlensiepen F, Mählmann S, von Peter S, Pieper D, Neugebauer E, Prediger B. Does the second opinion directive in Germany reach the patient? A parallel-convergent mixed-methods study. BMC Health Serv Res 2023; 23:1198. [PMID: 37924040 PMCID: PMC10623803 DOI: 10.1186/s12913-023-10197-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND A Second Opinion Directive (SOD) was introduced in Germany in December 2018 for elective surgeries such as hysterectomy, tonsillotomy, tonsillectomy, and shoulder arthroscopy. The aim of the SOD is to avoid surgeries which are not medically induced and to support patients in their decision-making process. A physician who indicates an SOD-relevant procedure must inform the patient about the SOD and its specifications. At this time, it is not clear whether physicians provide information about the SOD to patients and whether and how the SOD is implemented in daily practice. Furthermore, nothing is known about how patients react when they are told that they have the right to seek a second opinion according to the SOD. METHODS To assess this, we undertook a parallel-convergent mixed-methods study with a qualitative and quantitative phase. Qualitative data were analysed by structured qualitative content analysis and survey data were analysed descriptively. RESULTS 26 interviews were conducted with patients for whom one of the above-mentioned surgeries was indicated. In parallel, a questionnaire survey with 102 patients was conducted. The results show that the SOD is not implemented in Germany for the selected indications because patients were not informed as intended. At the same time, when the right to obtain a second opinion was explained, it seemed to have a positive effect on the physician-patient relationship from patients` perspective. CONCLUSIONS It is possible that there is a lack of information for physicians, which in turn leads to an information deficit for patients. Better information for physicians might be part of the solution, but a negative attitude towards the SOD might also result in the low education rate. Therefore, in addition, potential patients or even the general population should be better informed about the possibility of obtaining a second opinion.
Collapse
Affiliation(s)
- Susann May
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
| | - Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Angelina Glatt
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Dunja Bruch
- Department of Cardiovascular Surgery, Brandenburg Heart Center, Brandenburg Medical School Theodor Fontane, 16321, Bernau bei Berlin, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany
| | - Felix Muehlensiepen
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany
| | - Sonja Mählmann
- Institute for Health Services and Health System Research, Faculty for Health Sciences, Brandenburg Medical School, 15562, Rüdersdorf, Germany
| | | | - Dawid Pieper
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
- Institute for Health Services and Health System Research, Faculty for Health Sciences, Brandenburg Medical School, 15562, Rüdersdorf, Germany
| | - Edmund Neugebauer
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany.
| |
Collapse
|
5
|
Conte de Oliveira MD, Fernandes HDS, Vasconcelos AL, Russo FADP, Malheiro DT, Colombo G, Pelegrini P, Berwanger O, Teich V, Marra A, Menezes FGD, Cendoroglo Neto M, Klajner S. Impact of a quality programme on overindication of surgeries for endometriosis and cholecystectomies. BMJ Open Qual 2023; 12:e002178. [PMID: 37963671 PMCID: PMC10649569 DOI: 10.1136/bmjoq-2022-002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/01/2023] [Indexed: 11/16/2023] Open
Abstract
Approximately 45% of patients receive medical services with minimal or no benefit (low-value care). In addition to the increasing costs to the health system, performing invasive procedures without an indication poses a potentially preventable risk to patient safety. This study aimed to determine whether a managed quality improvement programme could prevent cholecystectomy and surgery for endometriosis treatment with minimal or no benefit to patients.This before-and-after study was conducted at a private hospital in São Paulo, Brazil, which has a main medical remuneration model of fee for service. All patients who underwent cholecystectomy or surgery for endometriosis between 1 August 2020 and 31 May 2021 were evaluated.The intervention consisted of allowing the performance of procedures that met previously defined criteria or for which the indications were validated by a board of experts.A total of 430 patients were included in this analysis. The programme prevented the unnecessary performance of 13% of cholecystectomies (p=0.0001) and 22.2% (p=0.0006) of surgeries for the treatment of endometriosis. This resulted in an estimated annual cost reduction to the health system of US$466 094.93.In a hospital with a private practice and fee-for-service medical remuneration, the definition of clear criteria for indicating surgery and the analysis of cases that did not meet these criteria by a board of reputable experts at the institution resulted in a statistically significant reduction in low-value cholecystectomies and endometriosis surgeries.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Vanessa Teich
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
6
|
Lafrance S, Vincent R, Demont A, Charron M, Desmeules F. Advanced practice physiotherapists can diagnose and triage patients with musculoskeletal disorders while providing effective care: a systematic review. J Physiother 2023; 69:220-231. [PMID: 37714771 DOI: 10.1016/j.jphys.2023.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 06/19/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023] Open
Abstract
QUESTIONS What is the diagnostic and surgical triage concordance between advanced practice physiotherapists (APPTs) and physicians? What is the clinical efficacy of advanced practice physiotherapy care compared with usual medical care? DESIGN Systematic review with meta-analyses. LITERATURE SEARCH Medline, Embase, Cochrane CENTRAL and CINAHL were searched up to March 2022. STUDY SELECTION CRITERIA Concordance studies on diagnostic or surgical triage between APPTs and physicians and randomised controlled trials comparing the clinical efficacy of an advanced practice physiotherapy (APP) model of care compared with usual medical care for participants with musculoskeletal disorders. DATA SYNTHESIS Meta-analyses were performed for concordance and clinical outcomes. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to evaluate the certainty of evidence. RESULTS Nineteen concordance studies (n = 1,745) and six randomised trials (n = 1,960) were included. Based on moderate-certainty evidence, the pooled Kappa for diagnostic concordance between APPTs and physicians was 0.76 (95% CI 0.68 to 0.85, n = 1,108). Based on high-certainty evidence, the pooled Kappa for surgical triage concordance was 0.71 (95% CI 0.63 to 0.78, n = 1,128). Based on moderate-certainty evidence, APP care resulted in a comparable or greater reduction in pain (MD -0.92 out of 10, 95% CI -1.75 to -0.10, n = 494) when compared with usual medical care at medium-term follow-up. Based on low-certainty evidence, APP care resulted in a comparable or greater reduction in disability (SMD -0.31, 95% CI -0.67 to 0.04, n = 535) when compared with usual medical care at medium-term follow-up. CONCLUSION Concordance between APPTs and physicians is probably good to very good for diagnosis and good to very good for surgical triage of musculoskeletal disorders. Patients with musculoskeletal disorders managed in an APP model of care probably report comparable or greater pain and disability reductions when compared with usual medical care. REGISTRATION CRD42022320950.
Collapse
Affiliation(s)
- Simon Lafrance
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada.
| | - Raphaël Vincent
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| | | | - Maxime Charron
- Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada; Hôpital Maisonneuve-Rosemont Research Center, Université de Montréal Affiliated Research Center, Montreal, Canada
| |
Collapse
|
7
|
AlAli KF. Unnecessary spine surgery: can we solve this ongoing conundrum? Front Surg 2023; 10:1270975. [PMID: 37693642 PMCID: PMC10491010 DOI: 10.3389/fsurg.2023.1270975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023] Open
|
8
|
Using general practitioners with an extended role in spinal practice for the initial assessment of patients referred to spinal surgeons: preliminary experience and challenges. Prim Health Care Res Dev 2023; 24:e9. [PMID: 36700455 PMCID: PMC9884532 DOI: 10.1017/s1463423622000494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
AIM To describe experience using general practitioners (GPs), with an extended role (GPwER) in spinal medicine, to expedite assessment, triage, and management of patients referred from primary care for specialist spinal surgical opinion. BACKGROUND Low back and neck pain are common conditions in primary care. Indiscriminate or inappropriate referral to a spinal surgeon contributes to long waiting times. Previous attempts at triaging patients who really require a surgical opinion have used practice nurses, physiotherapists, clinical algorithms, and interdisciplinary screening clinics. METHODS Within the setting of an independent spinal care centre, we have used GPs specially trained in spinal practice to expedite the assessment and triage of new referrals between 2015 and 2021. We reviewed feedback from a Patient Satisfaction Questionnaire and the postgraduate backgrounds, training, practice with regard to triage of new referrals, and experiences of the GPs who were recruited. FINDINGS Six GPwER had a mean of 26 years of postgraduate experience before appointment (range 10-44 years). The first four GPwER, appointed between 2015 and 2018, underwent an ad hoc in-house, interdisciplinary training programme and saw 2994 new patients between 2016 and 2020. After GPwER, assessment in only 18.9% (range 12.6 to 22.7%) of these patients was a spinal surgical opinion deemed necessary. Waiting times to see the spinal surgeon remained at 6-8 weeks despite a three-fold annual increase (from 340 to 1058) in new referrals. A Patient Satisfaction Questionnaire revealed high levels of satisfaction with the performances of the GPwER across seven dimensions. A dedicated training programme was designed in 2020, and the last two appointees underwent 20 h of clinical teaching prior to practice. Initial experience using GPwER, here termed 'Spinal Clinicians', suggests they are efficient at screening for patients needing spinal surgical referral. Establishing a recognised training programme, assessment, and certification for these practitioners are the next challenges.
Collapse
|
9
|
[Second opinion on spine surgery : Indication rarely confirmed and conservative treatment options are worthwhile]. Schmerz 2022; 37:175-184. [PMID: 35781748 DOI: 10.1007/s00482-022-00656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/23/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Second opinion (SO) on spine surgery was recently implemented as a statutory right in Germany. Prior to this, one health insurer did offer SO to its policy holders including advice on additional conservative treatment options. OBJECTIVES Which treatment recommendations did 522 patients receive in an interdisciplinary multimodal assessment (IMA) as part of a SO by 4 teams comprising physician, physio- and psychotherapist and what were the long-term consequences? METHODS Second opinions under a selective contract between insurer and back pain centers were evaluated based on patient-related anamnesis and interdisciplinary multimodal clinical findings including treatment recommendations and patient reports after about 2 years. RESULTS Initially, spine surgery recommendation was confirmed in 15/522 (2.9%) patients (C-SS) versus 507 recommendations against. C‑SS patients were older, male, and had current high pain intensity more frequently, their well-being and quality of life were more often considerably impaired and from the perspective of the team morphological findings were stronger. Younger and female patients with higher pain grade and less previous surgery, but more visits to medical specialties received more often a recommendation of an interdisciplinary treatment option (ITO) versus standard care (SC). After 2 years, all 15 C-SS patients and 146 randomly selected patients were contacted. Of these 161 patients, 29 (18%) had undergone spine surgery. The long-term outcome was best in ITO patients without surgery, followed by the C‑SS after surgery and SC patients without surgery. DISCUSSION Most patients undergoing spine surgery make their decision based on the information that they are provided without requesting a SO. As in comparative studies, most patients with a confirmed surgical indication underwent surgery, while some did not. Some patients underwent surgery inspite of recommendations against-after considering conservative therapy recommendations by the IMA. In retrospect, sound advice and an intensive conservative therapy offer seem necessary and reasonable.
Collapse
|
10
|
Abstract
STUDY DESIGN Delphi expert panel consensus. OBJECTIVE To obtain expert consensus on best practices for appropriate telemedicine utilization in spine surgery. SUMMARY OF BACKGROUND DATA Several studies have shown high patient satisfaction associated with telemedicine during the COVID-19 peak pandemic period as well as after easing of restrictions. As this technology will most likely continue to be employed, there is a need to define appropriate utilization. METHODS An expert panel consisting of 27 spine surgeons from various countries was assembled in February 2021. A two-round consensus-based Delphi method was used to generate consensus statements on various aspects of telemedicine (separated as video visits or audio visits) including themes, such as patient location and impact of patient diagnosis, on assessment of new patients. Topics with ≥75% agreement were categorized as having achieved a consensus. RESULTS The expert panel reviewed a total of 59 statements. Of these, 32 achieved consensus. The panel had consensus that video visits could be utilized regardless of patient location and that video visits are appropriate for evaluating as well as indicating for surgery multiple common spine pathologies, such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy. Finally, the panel had consensus that video visits could be appropriate for a variety of visit types including early, midterm, longer term postoperative follow-up, follow-up for imaging review, and follow-up after an intervention (i.e., physical therapy, injection). CONCLUSION Although telemedicine was initially introduced out of necessity, this technology most likely will remain due to evidence of high patient satisfaction and significant cost savings. This study was able to provide a framework for appropriate telemedicine utilization in spine surgery from a panel of experts. However, several questions remain for future research, such as whether or not an in-person consultation is necessary prior to surgery and which physical exam maneuvers are appropriate for telemedicine.Level of Evidence: 4.
Collapse
|
11
|
Könsgen N, Prediger B, Schlimbach A, Bora AM, Weißflog V, Loh JC, Bruch D, Pieper D. Telemedical Second Opinions in Germany: A Customer Survey of an Online Portal. Telemed J E Health 2022; 28:1664-1671. [PMID: 35394825 DOI: 10.1089/tmj.2022.0070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Introduction: Second medical opinions (SOs) can strengthen patients' certainty in decision making. In Germany, both personally delivered and telemedical SOs (often based on documents only) are provided. Our aim was to analyze the experiences of people who obtained telemedical SOs. We also investigated different routes of SO delivery (personally/by phone/documents only). Materials and Methods: German residents who obtained a telemedical SO via an online portal between January 2016 and February 2019 (n = 1,247) were contacted by post between August and November 2019 up to three times. The results were analyzed descriptively. Results: The 368 participants (response rate 30%) were 54% male, 95% statutory health insured, and 61 years old (median; interquartile range 51-72). Approximately 75% were (rather) satisfied with obtaining the SO via the online portal. The most preferred route of SO delivery was a personally delivered SO, which 80% would (rather) consider, followed by 70% (rather) considering SOs based on documents only and 48% (rather) considering SOs by phone. The most often mentioned advantage of telemedical SOs was independence of time and place, while the most important disadvantage was the standardized process resulting in a lack of direct and personal contact between the patient and the physician. Discussion: Although our results show that SOs (based on documents only) support patients and that patient satisfaction was high, personally delivered SOs were still preferred. Future research on the use of SOs based on documents only (in which patient population and in what situations) is needed.
Collapse
Affiliation(s)
- Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Anna Schlimbach
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Ana-Mihaela Bora
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | | | | | - Dunja Bruch
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Neuruppin, Brandenburg, Germany
- Center for Health Services Research, and Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
- Center for Health Services Research, and Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| |
Collapse
|
12
|
Oliveira RBD, Oliveira IOD, Antonioli E, Lenza M, Ferretti M. Clinical outcome analysis in surgical patients enrolled in a Second Opinion Program in spine surgery. EINSTEIN-SAO PAULO 2022; 20:eAO5791. [PMID: 35384982 PMCID: PMC8967312 DOI: 10.31744/einstein_journal/2022ao5791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/26/2021] [Indexed: 12/05/2022] Open
Abstract
Objective To analyze pain, functional capacity, quality of life, anxiety and depression outcomes in patients undergoing lumbar spine surgery following use of the Second Opinion Program, and to present disagreements regarding diagnoses and therapeutic indications between the first and second opinions. Methods A prospective, observational cohort study with 100 patients enrolled in the Second Opinion Program who underwent lumbar spine surgery. Questionnaires addressing pain intensity, level of disability, quality of life, anxiety and depression were applied prior to and within 1, 3, 6 and 12 months of surgery. Descriptive and comparative statistical analyses were performed. The following clinical outcomes were analyzed: pain intensity, level of disability, quality of life, anxiety, and depression. Results In this sample, 88% and 12% out of 100 patients were submitted to lumbar decompression and arthrodesis, respectively. Patients reported improvements in function, pain intensity, and quality of life factors following surgery and were able to attain the minimal clinically important difference relative to the preoperative period. Agreement between the first and second opinions was observed in 44% of diagnoses, and in 27% of therapeutic indications. Conclusion Patients had favorable postoperative outcomes regarding pain, disability, and quality of life. These findings and the high rates of diagnostic and therapeutic indication disagreements corroborate the need of a second opinion in cases of spine disease with surgical indications.
Collapse
|
13
|
Ferreira GE, Zadro J, Liu C, Harris IA, Maher CG. Second opinions for spinal surgery: a scoping review. BMC Health Serv Res 2022; 22:358. [PMID: 35300677 PMCID: PMC8932184 DOI: 10.1186/s12913-022-07771-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. METHODS We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively. RESULTS We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections). CONCLUSIONS Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.
Collapse
Affiliation(s)
- Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia. .,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia.
| | - Joshua Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Chang Liu
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| |
Collapse
|
14
|
Könsgen N, Prediger B, Schlimbach A, Bora AM, Hess S, Caspers M, Pieper D. Attitude toward second opinions in Germany - a survey of the general population. BMC Health Serv Res 2022; 22:76. [PMID: 35033078 PMCID: PMC8760563 DOI: 10.1186/s12913-021-07422-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/15/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Second medical opinions (SOs) can assist patients in making informed treatment decisions and improve the understanding of their diagnosis. In Germany, there are different approaches to obtain a structured SO procedure: SO programs by health insurers and SOs according to the SO Directive. Through a direct survey of the population, we aimed to assess how structured SOs should be provided to fulfil patients' needs. METHODS A stratified sample of 9990 adults (≥18 years) living in the federal states of Berlin and Brandenburg (Germany) were initially contacted by post in April and sent a reminder in May 2020. The survey results were analyzed descriptively. RESULTS Among 1349 participants (response rate 14%), 56% were female and the median age was 58 years (interquartile range (IQR) 44-69). Participants wanted to be informed directly and personally about the possibility of obtaining an SO (89%; 1201/1349). They preferred to be informed by their physician (93%; 1249/1349). A majority of participants would consider it important to obtain an SO for oncological indications (78%; 1049/1349). Only a subset of the participants would seek an SO via their health insurer or via an online portal (43%; 577/1349 and 16%; 221/1349). A personally delivered SO was the preferred route of SO delivery, as 97% (1305/1349) would (tend to) consider this way of obtaining an SO. Participants were asked to imagine having moderate knee pain for years, resulting in a treatment recommendation for knee joint replacement. They were requested to rate potential qualification criteria for a physician providing the SO. The criteria rated to be most important were experience with the recommended diagnosis/treatment (criterion (very) important for 93%; 1257/1349) and knowledge of the current state of research (criterion (very) important for 86%; 1158/1349). Participants were willing to travel 60 min (median; IQR 60-120) and wait 4 weeks (median; IQR 2-4) for their SO in the hypothetical case of knee pain. CONCLUSION In general, SOs were viewed positively. We found that participants have clear preferences regarding SOs. We propose that these preferences should be taken into account in the future design and development of SO programs.
Collapse
Affiliation(s)
- Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Anna Schlimbach
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Ana-Mihaela Bora
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Michael Caspers
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Institute for Health Services and Health System Research, Neuruppin, Germany
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| |
Collapse
|
15
|
Kassouf V, Sagherian BH, Yassin K, Antoun J. Effect of a discordant opinion offered by a second opinion physician on the patient's decision for management of spinal disc disease. PATIENT EDUCATION AND COUNSELING 2022; 105:228-232. [PMID: 33985847 DOI: 10.1016/j.pec.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Factors that influence a patient's decision for spinal surgery and selection of the spine surgeon have not been studied in the context of a Second Opinion (SO). Providing insight into these factors will guide surgeons in their discussion of treatment options with patients. OBJECTIVE This study aims to assess the impact of a discordant SO on the final decision of patients as compared to their initial preference regarding spinal disc disease treatment for chronic neck and low back pain. PATIENT INVOLVEMENT Patients in this study engage in clinical vignettes designed to induce decisional conflict. METHODS A cross-sectional study using clinical vignette-based questionnaires was presented to patients at the Family Medicine, Orthopedic, and Neurosurgery clinics at a university-based tertiary academic medical center. RESULTS A total of 246 patients participated in the study (response rate, 66.8%). Irrespective of the initial offered treatment, most patients wanted to consult a SO (64.2%). Most patients preferred conservative treatment to surgery after getting the initial recommendation (78.5%) and after getting a discordant SO (56.5%). There was an association between the agreement of the patient with the initial recommendation and the effect of the SO on the final decision of patients (p < 0.001). Patients who disagreed with the initially offered treatment were more likely to abide by their initial decision after the SO (80.8%) as compared to those who were in agreement (17.7%), while those who agreed with the initially offered treatment were more likely to change their decision (39.5%) or to take a third opinion (42.9%). DISCUSSION A discordant SO may validate patients' wishes when they disagree with the initially offered treatment and may lead to confusion when they agree with the initial physicians' recommendations. PRACTICAL VALUE As patients tend to abide by their initial preference, physicians should explicitly consider patients' wishes when discussing options for management of spinal disc disease.
Collapse
Affiliation(s)
- Vicky Kassouf
- Department of Family Medicine, American University of Beirut, Lebanon
| | - Bernard H Sagherian
- Division of Orthopedic Surgery / Department of Surgery, American University of Beirut, Lebanon
| | - Koumail Yassin
- Department of Arts and Science, American University of Beirut, Lebanon
| | - Jumana Antoun
- Department of Family Medicine, American University of Beirut, Lebanon.
| |
Collapse
|
16
|
Gattas S, Fote GM, Brown NJ, Lien BV, Choi EH, Chan AY, Rosen CD, Oh MY. Second opinion in spine surgery: A scoping review. Surg Neurol Int 2021; 12:436. [PMID: 34513199 PMCID: PMC8422531 DOI: 10.25259/sni_399_2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/05/2021] [Indexed: 01/13/2023] Open
Abstract
Background: As a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery. Methods: Utilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years. Results: We identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures. Conclusion: The 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery.
Collapse
Affiliation(s)
- Sandra Gattas
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States.,Department of Electrical Engineering and Computer Science, University of California Irvine Medical Center, Irvine, CA, United States.,Department of Medical Scientist Training Program, University of California Irvine Medical Center, Irvine, CA, United States
| | - Gianna M Fote
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States.,Department of Medical Scientist Training Program, University of California Irvine Medical Center, Irvine, CA, United States.,Department of Biological Chemistry, University of California Irvine Medical Center, Irvine, CA, United States
| | - Nolan J Brown
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| | - Brian V Lien
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| | - Charles D Rosen
- Orthopedic Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| | - Michael Y Oh
- Department of Neurological Surgery, University of California Irvine Medical Center, Irvine, CA, United States
| |
Collapse
|
17
|
Sanchez S, Adamowicz I, Chrusciel J, Denormandie P, Denys P, Degos L. Predictive factors of diagnostic and therapeutic divergence in a nationwide cohort of patients seeking second medical opinion. BMC Health Serv Res 2021; 21:902. [PMID: 34470642 PMCID: PMC8408960 DOI: 10.1186/s12913-021-06936-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the profile of patients who sought a second medical opinion (SMO) on their therapeutic or diagnostic strategy using nationwide data from a French physician network dedicated to SMOs. METHODS An observational cohort study was conducted and the study population consisted of patients residing in France or in the French overseas territories who submitted a request for an SMO through a dedicated platform between January 2016 and October 2020. Patient characteristics were compared between convergent and divergent SMOs. The divergent rate for all patients excluding those with mental diseases were described. Logistic regression was used to estimate the probability of a divergent SMO according to patient characteristics. RESULTS AND DISCUSSION In total, 1,552 adult patients over several French regions were included. The divergence rate was 32.3 % (n = 502 patients). Gynecological [Odds Ratio (OR) and 95 % CI: 5.176 (3.154 to 8.494)], urological [OR 4.246 (2.053 to 8.782)] and respiratory diseases [OR 3.639 (1.357 to 9.758)] had the highest probability of a divergent SMO. Complex cases were also associated with a significantly higher risk of a divergent opinion [OR 2.78 (2.16 to 3.59)]. Age, sex, region and profession were not found to be predictive of a divergent second opinion. CONCLUSIONS Policymakers should encourage new research on patient outcomes such as mortality and hospitalization rates after a SMO. When proven effective, SMO networks will have the potential to benefit from specific public funding or even play a key role in national healthcare quality improvement programs.
Collapse
Affiliation(s)
- Stéphane Sanchez
- Public Health and Performance Department, Champagne Sud Hospitals, 101 avenue Anatole France, 10000, Troyes, France.
| | | | - Jan Chrusciel
- Public Health and Performance Department, Champagne Sud Hospitals, 101 avenue Anatole France, 10000, Troyes, France
| | | | - Pierre Denys
- Urology and Neurology Rehabilitation Department, Raimond Poincaré Hospital, APHP, Garches, France
| | | |
Collapse
|
18
|
Ramos P, Savage C, Thor J, Atun R, Carlsson KS, Makdisse M, Neto MC, Klajner S, Parini P, Mazzocato P. It takes two to dance the VBHC tango: A multiple case study of the adoption of value-based strategies in Sweden and Brazil. Soc Sci Med 2021; 282:114145. [PMID: 34192620 DOI: 10.1016/j.socscimed.2021.114145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 04/23/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022]
Abstract
Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs - not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.
Collapse
Affiliation(s)
- Pedro Ramos
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden; Hospital Israelita Albert Einstein, Brazil.
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | - Johan Thor
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, USA
| | - Karin Solberg Carlsson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| | | | | | | | - Paolo Parini
- Theme Inflammation and Infection, Karolinska University Hospital, Sweden; H7 Medicin, Huddinge, Endokrinologi och diabetes, Karolinska Institutet, Sweden
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Sweden
| |
Collapse
|
19
|
Könsgen N, Prediger B, Bora AM, Glatt A, Hess S, Weißflog V, Pieper D. Analysis of second opinion programs provided by German statutory and private health insurance - a survey of statutory and private health insurers. BMC Health Serv Res 2021; 21:209. [PMID: 33750368 PMCID: PMC7941885 DOI: 10.1186/s12913-021-06207-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/22/2021] [Indexed: 01/12/2023] Open
Abstract
Background Second medical opinions can give patients confidence when choosing among treatment options and help them understand their diagnosis. Health insurers in several countries, including Germany, offer formal second opinion programs (SecOPs). We systematically collected and analyzed information on German health insurers’ approach to SecOPs, how the SecOPs are structured, and to what extent they are evaluated. Methods In April 2019, we sent a questionnaire by post to all German statutory (n = 109) and private health insurers (n = 52). In September 2019, we contacted the nonresponders by email. The results were analyzed descriptively. They are presented overall and grouped by type of insurance (statutory/private health insurer). Results Thirty one of One hundred sixty one health insurers (response rate 19%) agreed to participate. The participating insurers covered approximately 40% of the statutory and 34% of the private health insured people. A total of 44 SecOPs were identified with a median of 1 SecOP (interquartile range (IQR) 1–2) offered by a health insurer. SecOPs were in place mainly for orthopedic (21/28 insurers with SecOPs; 75%) and oncologic indications (20/28; 71%). Indications were chosen principally based on their potential impact on a patient (22/28; 79%). The key qualification criterion for second opinion providers was their expertise (30/44 SecOPs; 68%). Second opinions were usually provided based on submitted documents only (21/44; 48%) or on direct contact between a patient and a doctor (20/44; 45%). They were delivered after a median of 9 days (IQR 5–15). A median of 31 (IQR 7–85) insured persons per year used SecOPs. Only 12 of 44 SecOPs were confirmed to have conducted a formal evaluation process (27%) or, if not, plan such a process in the future (10/22; 45%). Conclusion Health insurers’ SecOPs focus on orthopedic and oncologic indications and are based on submitted documents or on direct patient-physician contact. The formal evaluation of SecOPs needs to be expanded and the results should be published. This can allow the evaluation of the impact of SecOPs on insured persons’ health status and satisfaction, as well as on the number of interventions performed. Our results should be interpreted with caution due to the low participation rate. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06207-8.
Collapse
Affiliation(s)
- Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Ana-Mihaela Bora
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Angelina Glatt
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | | | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| |
Collapse
|
20
|
Is there bias in the treatment of degenerative spine disease? Analysis of anonymous voting via a multidisciplinary conference. J Clin Neurosci 2020; 82:141-146. [PMID: 33317723 DOI: 10.1016/j.jocn.2020.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/07/2020] [Accepted: 10/18/2020] [Indexed: 11/20/2022]
Abstract
Many institutions have developed shared decision-making conferences as a mechanism for reducing treatment costs and improving patient outcomes. Little is known about the process of shared decision-making that takes place in these conferences, and there is the possibility of bias among surgeons and nonsurgeons for treatment within their respective specialties. This study was conducted to determine who is contributing to the decision-making process in a multidisciplinary spine conference and to what extent treatment biases exist among the surgical and nonsurgical members of this conference. Voting data were collected during weekly multidisciplinary spine conferences. Descriptive statistics were calculated on the cases presented and the number and type of physicians voting for each case. The likelihood of a particular vote in the surgeon and nonsurgeon cohorts was evaluated using relative risk calculation and multinomial logistic regression. A total of 262 consecutive cases were analyzed. No significant differences in treatment recommendation were observed between surgery and nonsurgical management (relative risk, 1.1; 95% CI, 0.97-1.25) when comparing votes from the surgeon and nonsurgeon cohorts. Multinomial logistic regression showed the odds of nonsurgeons recommending nonsurgical management over surgery was 20% greater than receiving that recommendation from their surgeon colleagues. Individual surgeon and nonsurgeon voters were evenly distributed above and below the mean for treatment recommendation. Individual and group biases exist among surgeons and nonsurgeons treating degenerative spine diseases. Multidisciplinary conferences may or may not level these biases, depending on how they are conducted.
Collapse
|
21
|
Burger PM, Westerink J, Vrijsen BEL. Outcomes of second opinions in general internal medicine. PLoS One 2020; 15:e0236048. [PMID: 32645107 PMCID: PMC7347190 DOI: 10.1371/journal.pone.0236048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/26/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND To date, the outcomes of second opinions in internal medicine in terms of diagnostic yield and patient benefit have not been studied extensively. This retrospective study explores the outcomes of second opinions at a general internal medicine outpatient clinic in an academic hospital. METHODS A register of all patients referred to the general internal medicine outpatient clinic of the University Medical Center in Utrecht for a second opinion, was kept. All 173 patients referred between June 2016 and August 2018 were selected. Case records were analyzed for patient characteristics, referring doctor, chief complaint, performed investigations, follow-up time and, established diagnosis, additional diagnoses, initiated treatment and reported benefit. RESULTS A new diagnosis was established in 13% of all patients. A new treatment was initiated in 56% of all patients: 91% and 51% of patients with and without a new diagnosis respectively (p < 0.001). Of all patients, 19% received an effective treatment (52% vs 14% of patients with vs without a new diagnosis, p < 0.001). Regardless of treatment, resolution or improvement of the chief complaint was achieved in 28% of all patients (52% vs 25% of patients with vs without a new diagnosis, p = 0.006). Regarding diagnostics, 23-33% of radiology, endoscopy and pathology tests performed during second opinion were a repetition of previously conducted investigations. Conventional blood tests were a repetition in 89% of cases. Median time to diagnosis was 64 days (IQR: 25-128 days) and median time to discharge was 75 days (IQR: 31-144 days). CONCLUSION Second opinions in general internal medicine lead to the establishment of a new diagnosis in a small proportion of patients. However, the value of second opinions may not be limited to the establishment of diagnoses, as new treatments are often initiated and overall patients report improved symptomatology in 28% of cases.
Collapse
Affiliation(s)
- Pascal M. Burger
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bram E. L. Vrijsen
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| |
Collapse
|
22
|
Weyerstraß J, Prediger B, Neugebauer E, Pieper D. Results of a patient-oriented second opinion program in Germany shows a high discrepancy between initial therapy recommendation and second opinion. BMC Health Serv Res 2020; 20:237. [PMID: 32192450 PMCID: PMC7083019 DOI: 10.1186/s12913-020-5060-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 02/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background As of 2015, second opinions are legally implemented in Germany. However, empirical results from German second opinion programs are lacking. The aim of this study was to examine several aspects within a population of a German second opinion program. Methods Study population consisted of patients who sought a second opinion in the period from August 2011 to December 2016. Multivariate logistic regression and ANOVA were used to examine differences in patient characteristics, differentiated by agreement of initial therapy recommendation and second opinion. Follow-up points for patient satisfaction and HRQoL were defined at 1, 3 and 6 months after obtaining the second opinion. Results Total number of patients who sought a second opinion was 1414. Most common indications concerned the knee (37.3%), spine (27.3%), hip (11.5%) and shoulder (10.1%). The independent specialists did not confirm the initial therapy recommendations in two out of three cases. The type of indication influenced the agreement between initial therapy recommendation and the second opinion significantly (p = 0.035). The second opinion and the offered service was highly valued by the patients (89%). Conclusions The second opinion offers patients the possibility to confirm a medical indication independently and support patients in their decision making process. Reasons for the large discrepancy between initial therapy recommendation and second opinion should be addressed in future research.
Collapse
Affiliation(s)
- Jan Weyerstraß
- University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, Witten, 58455, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.,Brandenburg Medical School Theodor Fontane (MHB), Brandenburg, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine (IFOM), Interim Head: Prof. Dr. Rolf Lefering, Chair of Surgical Research, Faculty of Health, School of Medicine, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| |
Collapse
|
23
|
Shmueli L, Shmueli E, Pliskin JS, Balicer RD, Davidovitch N, Hekselman I, Greenfield G. Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study. BMJ Open 2019; 9:e025673. [PMID: 31352409 PMCID: PMC6661653 DOI: 10.1136/bmjopen-2018-025673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare. DESIGN An observational study. SETTING Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel. PARTICIPANTS The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance. OUTCOMES MEASURES An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used. RESULTS 143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9). CONCLUSIONS Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.
Collapse
Affiliation(s)
- Liora Shmueli
- Department of Management, Bar Ilan University, Ramat Gan, Israel
| | - Erez Shmueli
- Department of Industrial Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Joseph S Pliskin
- Department of Industrial Engineering and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran D Balicer
- Epidemiology, Ben-Gurion University, Tel Aviv, Israel
- Clalit Research Institute, Tel Aviv, Israel
| | - Nadav Davidovitch
- Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Igal Hekselman
- Clalit Mushlam Health Insurance, Bnei Brak, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Geva Greenfield
- Department of Primary Care & Public Health, Imperial College London, London, UK
| |
Collapse
|
24
|
Benbassat J. Obtaining a second opinion is a neglected source of health care inequalities. Isr J Health Policy Res 2019; 8:12. [PMID: 30651143 PMCID: PMC6335699 DOI: 10.1186/s13584-019-0289-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 11/25/2022] Open
Abstract
Observational studies have detected discrepancies between two expert interpreters of imaging and histopathological studies. Furthermore, in a substantial proportion of patients, an independent second opinion disagreed with the first one. Therefore, it is widely accepted that patients have a right to obtain a second opinion and, in case of divergent opinions, to deliberate and choose the option that they believe is most consistent with their individual circumstances. However, doctors are less likely to inform old and poorly educated patients about the possibility of seeking a second opinion, and this may contribute to healthcare inequalities. Hence the importance of (a) promoting doctors’ self-awareness of a possible tendency to discriminate against old and poorly educated patients, and (b) creating programs within the healthcare system that would help patients in seeking a second opinion, suggest specialists for the specific problem of the patient, and provide tools to reconcile between discrepant opinions.
Collapse
Affiliation(s)
- Jochanan Benbassat
- Myers-JDC-Brookdale Institute, Department of Health Policy Research, PO Box 3886, 91037, Jerusalem, Israel.
| |
Collapse
|
25
|
Tackling low back pain in Brazil: a wake-up call. Braz J Phys Ther 2018; 23:189-195. [PMID: 30337255 DOI: 10.1016/j.bjpt.2018.10.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/28/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society. OBJECTIVE This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.
Collapse
|
26
|
Oliveira IOD, Lenza M, Vasconcelos RAD, Antonioli E, Cendoroglo Neto M, Ferretti M. Second opinion programs in spine surgeries: an attempt to reduce unnecessary care for low back pain patients. Braz J Phys Ther 2018; 23:1-2. [PMID: 30266561 DOI: 10.1016/j.bjpt.2018.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/04/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Isadora Orlando de Oliveira
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Instituto Wilson Mello, Campinas, SP, Brazil; Universidade Cidade de São Paulo, São Paulo, SP, Brazil
| | - Mario Lenza
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | | | | - Mário Ferretti
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| |
Collapse
|
27
|
Lackey AR, Turner Z, Haney CA, Stanfield AC, Kossoff EH. Evaluation of the Utility of a Dietary Therapy Second Opinion Clinic. J Child Neurol 2018; 33:290-296. [PMID: 29433418 DOI: 10.1177/0883073818754664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fine-tuning ketogenic diets to achieve better seizure control may influence families to seek second opinions. Since 2009, Johns Hopkins Hospital has provided second opinions for children followed at other ketogenic diet centers. We retrospectively reviewed 65 consecutive children seen in this clinic; parents were also sent a 2-page survey. The mean age was 6.6 years and dietary therapy had been used a median 9 months. Seizure reduction >50% was achieved in 65%, including 35% with >90% reduction. Parent questions included how to improve seizure control (65%), ideal diet duration (18%), and confirmation of the plan (11%). The most common recommendations were anticonvulsant reduction (43%), adding oral citrates/calcium/vitamins (38%), and carnitine supplementation (31%). Diet discontinuation was more frequently suggested in those children with <50% seizure reduction (60% vs 20%, P = .001). Recommendations were successful in 78%, and the visit was reported as useful by 88%.
Collapse
Affiliation(s)
| | - Zahava Turner
- 2 Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA.,3 Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Courtney A Haney
- 2 Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Eric H Kossoff
- 2 Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA.,3 Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
28
|
Value-Based Care and Musculoskeletal Rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0176-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|