Patients’ expectations of surgical outcomes need to be more realistic

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According to a new study presented at the 30th Annual Meeting of the North American Spine Society (NASS; 14-17 October, Chicago, USA), 87% of lumbar spine surgery patients had more optimistic expectations of surgical outcomes than their surgeons did, and only 11% of patients had lower expectations for their outcomes than their surgeons.

“While it may seem obvious that experienced surgeons would have a more realistic view of surgical outcomes than patients, this wide expectation gap is disturbing,” said Gwendolyn Sowa, a physiatrist and NASS Annual Meeting programme chair. “Before a surgery date is even scheduled, it is essential that the surgeon and patient have clear conversations about their expectations for the surgery, including recovery time, after care, and anticipated outcomes so that they can work toward the same goals.”

The study was selected as one of 21 “Best Papers” at the NASS meeting.

Most patients who elect to undergo lumbar surgery do so because they expect improvement in physical and psychological symptoms. The expectation of a positive outcome tends to be the driving force in their decision to have surgery. However, if a patient’s expectations are unrealistic, it can have a detrimental effect on the ultimate outcome. “If patient expectations are inappropriately high, patients may abandon rehabilitation too soon if they are not getting the results that they are expecting,” said Carol A Mancuso, the study’s lead author and an associate professor of Medicine at the Weill Cornell Medical College and the Graduate School of Medical Sciences and Associate Scientist at the Hospital for Special Surgery in New York, USA. “On the other hand, if expectations are too low, this may predispose patients to poor outcomes if they are unwilling to make certain lifestyle changes and to follow postoperative precautions that are necessary to maximize the benefit of the surgery.”

In an effort to measure the level of concordance between patients and surgeons regarding what the expectations should be for long-term recovery after lumbar spine surgery, the researchers conducted a cross-sectional study of 184 patients scheduled for lumbar surgery and their surgeons. Patients completed an expectations survey several days before their scheduled surgery. The survey consisted of 20 items that addressed symptoms, physical function and mental well-being, including questions about how much improvement they expected for each item after their surgery.

Based on the responses, the investigators generated a score for each patient, ranging from 0-100, with a higher score reflecting higher expectations. They then asked the surgeons to complete an identical survey asking them how much improvement they expected for each item for their specific patient.

For the first 184 patients enrolled in this ongoing study, the mean survey score for the patients was 73 and the mean score for the surgeons was 57. Eighty-seven per cent of patients had higher scores (ie. greater expectations) and 11% of patients had lower scores (ie. lesser expectations) than their surgeons, and for 43%, the difference exceeded a clinically important difference.

Concordance within each patient-surgeon pair was then calculated as the amount of agreement between the patient score and the surgeon score, with a concordance coefficient ranging from 0, if there is no agreement at all, to 1 for perfect agreement. The concordance in scores between patient-surgeon pairs for the entire sample was 0.37.

“These findings provide evidence that expectations should be discussed formally with patients before surgery, and the discussion should address both the breadth of items expected and the amount of improvement expected,” Mancuso said. “Our next step will be to develop a curriculum for patients that addresses realistic expectations for surgery. The content for the curriculum will be based on surgeons’ ratings regarding appropriate expectations for most patients according to diagnosis and preoperative status.”