Concordance between Patients' and Surgeons' Expectations of Lumbar Spine Surgery
Authors: Lebl Darren , Sama Andrew , Mancuso Carol A. , Duculan Roland , Cammisa Frank P. , Hughes Alex P. , Girardi Federico P. 
Published: April 2016

Background

Patients undergo lumbar surgery because they expect improvement in physical and psychological symptoms. Patients and surgeons need to share an understanding of what are possible, probable and realistic expectations so they can work toward the same goals. The objective of this study was to compare concordance (agreement) within the patient-surgeon pair regarding expectations of lumbar surgery. A cross-sectional study of 184 patients scheduled for lumbar surgery and their surgeons performed at a tertiary spine center

Methods

Patients scheduled for lumbar surgery were recruited from the practices of 5 spine surgeons and interviewed in person several days before surgery with several patient-centered questionnaires including the modified Oswestry Disability Index (ODI) (score range 0–100, higher is worse), the Geriatric Depression Scale (score range 0–30, ≥11 is a positive screen for depression) and the valid Lumbar Spine Surgery Expectations Survey. The 20-item Expectation Survey addresses symptoms, physical function, and psychological well-being, and asks how much improvement is expected with response options of “complete” (=4 points), “a lot” (=3 points), “a moderate amount” (=2 points), “a little” (=1 point), or “no improvement/this expectation does not apply to me” (=0 points). An overall score is calculated as the sum of all responses (range 0–100, higher is greater expectations); a clinically important difference is 20 points. Before surgery, surgeons completed an identical survey asking them to rate how much improvement they expected for each item for each of their patients. The surgeon's survey is scored similarly to generate an overall score (range 0–100). Concordance between scores for each patient-surgeon pair was measured with the intraclass correlation coefficient (ICC) for continuous data [range -1 (perfect disagreement), 0 (agreement no better than chance); +1 (perfect agreement)].

Results

Patients completed the Expectations Survey a mean of 10 days before surgery; mean age 54 years, 51% men, mean ODI score 54 ± 13, 33% had a positive screen for depression, 16% had a diagnosis of acute herniated nucleus pulposus, and 84% had a degenerative condition. The 5 surgeons were age 37–59 years, in practice for 4–27 years, and all had completed a spine fellowship. The number of patients per surgeon ranged from 22–57. The mean Expectation Survey score was 73 ± 19 for patients and 57 ± 16 for surgeons. 87% of patients had higher scores (i.e., greater expectations) and 11% of patients had lower scores (i.e., lesser expectations) than their surgeons, and for 43% the difference exceeded a clinically important difference. The concordance in scores (ICC) between patient-surgeon pairs for the entire sample was 0.37. There were differences in ICC based on: demographic characteristics [men (0.47) versus women (0.27)]; diagnosis [acute herniated nucleus pulposus (0.55) versus degenerative condition (0.32)]; psychological status [negative screen for depression (0.43) versus positive screen for depression (0.22)]; and disability [better ODI score (0.46) versus worse ODI score (0.23)].

Conclusions

There was wide variation in expectation scores between patients and their surgeons and for more than one third of patients this exceeded a clinically important difference. Lower concordance was not exclusively related to any particular feature but was associated with demographic, diagnostic, and clinical characteristics.