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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.
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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
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Kisch R, Grill E, Müller M, Pietzner J, Paulus AC, Weigl M. Second opinion and time to knee arthroplasty: a prospective cohort study of 142 patients. BMJ Open 2023; 13:e073497. [PMID: 37827748 PMCID: PMC10582995 DOI: 10.1136/bmjopen-2023-073497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to determine the impact of obtaining a second opinion consultation on time to knee arthroplasty (KA). We further examined the frequency of KA and the determinants of KA following the second opinion. DESIGN Prospective cohort study. SETTING The second opinion programme was implemented at the Ludwig Maximilian University Hospital in Munich. PARTICIPANTS Participants comprised patients with knee osteoarthritis who were insured with one of the largest statutory health insurance Allgemeine Ortskrankenkasse Bayern (mean age 64.3±9.6 years). Patients participated in a second-opinion programme and completed questionnaires on site before and after personal presentation for the second opinion consultation. Follow-up questionnaires were delivered by post at 3 and 12 months after the second opinion consultation. Of the 142 patients included in the study, 47 (33.1%) underwent KA within 12 months after obtaining the second opinion. PRIMARY OUTCOME MEASURES Primary outcome measure was time until patients received KA. Cox proportional hazard modelling was used to calculate the associations between the selected predictors and time that elapsed between receipt of the second opinion to KA. RESULTS Mean time until KA was 17 weeks. Kaplan-Meier curves showed significant differences in time to KA according to the recommendation given at second opinion consultation, knee-related quality of life and Kellgren-Lawrence grade. In multivariate Cox proportional hazard modelling, second opinion recommendation (HR 5.33, 95% CI 1.16, 24.41) and knee-related quality of life (HR 1.03, 95% CI 1.01, 1.06) were significant predictors of time from second opinion to KA. CONCLUSIONS Obtaining a second opinion had significant impact on time to knee replacement. Those who were recommended immediate surgery also underwent surgery more quickly after the second opinion. The effect of knee-related quality of life supports the importance of patient-reported outcome measures in the decision for or against KA.
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Affiliation(s)
- Rebecca Kisch
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
- German Centre for Vertigo and Balance Disorders, University Hospital Munich, Munchen, Germany
| | - Martin Müller
- Department for Primary Care and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Jens Pietzner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital Munich, Munchen, Germany
| | - Alexander C Paulus
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital Munich, Munchen, Germany
| | - Martin Weigl
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital Munich, Munchen, Germany
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[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.
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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.
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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
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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.
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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
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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.
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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
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Weigl M, Pietzner J, Kisch R, Paulus A, Jansson V, Grill E. Effects of a medical second opinion programme on patients' decision for or against knee arthroplasty and their satisfaction with the programme. BMC Musculoskelet Disord 2021; 22:595. [PMID: 34182959 PMCID: PMC8240280 DOI: 10.1186/s12891-021-04465-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND German social legislation gives patients the right to obtain a second opinion before elective surgery and defines quality criteria for reimbursement by statutory health insurances. However, the effects of second opinions before elective surgery are largely unknown. The aim of this study was to evaluate the effects of a second opinion programme in patients recommended for knee arthroplasty. METHODS The largest statutory health insurance funds in Bavaria offered patients who had been recommended to have knee arthroplasty the opportunity to partake in a second opinion programme which consisted of an in person presentation to an experienced knee surgeon. In this cohort study, consecutive patients from this second opinion programme who signed informed consent were included from 07/10/2016 to 14/02/2020. Data were collected before and after the second opinion visit. RESULTS A total of 141 (66%) of 215 patients who presented for a second opinion participated in the evaluation study. The second opinion physician recommended knee arthroplasty to 40% of the patients, later knee arthroplasty if the conditions worsened to 40%, and no knee arthroplasty to 20%. After receiving the second opinion 28 of 56 (41%) undecided patients preferred knee arthroplasty, 14 no knee arthroplasty, 14 remained undecided. Four of 46 patients with a preference for "arthroplasty" changed their decision to "no arthroplasty", five of 35 patients from "no arthroplasty" to "arthroplasty". The patients were more confident in their decision according to the decision confidence scale (before: 5.4 ± 3.0; after: 7.8 ± 2.5; p < 0.001). They rated their satisfaction with the second opinion programme with a mean grade of 1.35 (± 0.60) (best:1; worst:6). Logistic regression analyses showed that the recommendation of the second opinion physician for joint arthroplasty was associated with the guideline criteria radiological severity of osteoarthritis (p = 0.001) and knee-joint-specific quality of life (p = 0.041). CONCLUSION The second opinion of an experienced knee surgeon frequently deviates from the initial recommendation for knee arthroplasty. The association of guideline criteria to the second recommendation suggests a high quality of the second opinion. From the patient perspective, the second opinion reduces uncertainties in their treatment decision.
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Affiliation(s)
- Martin Weigl
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistr. 15, D-81377, Munich, Germany.
| | - Jens Pietzner
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistr. 15, D-81377, Munich, Germany.,Kliniken an der Paar, Aichach und Friedberg, Germany
| | - Rebecca Kisch
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians Universität München, Munich, Germany
| | - Alexander Paulus
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Volkmar Jansson
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistr. 15, D-81377, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians Universität München, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians Universität München, Munich, Germany
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