Patient Preferences and Expectations for Care: Determinants in Patients With Lumbar Intervertebral Disc Herniation

Patient expectations about treatment effectiveness have been shown to have an important—though complex—relationship with their clinical outcomes and satisfaction with treatment. Patient expectations for improvement with spine surgery have generally been shown to be quite high.1,2 Unrealistically high expectations have been thought to be responsible for unmet expectations and decreased patient satisfaction.1-5 On the other hand, the expectation of benefit is felt to result in improvement in symptoms and function through “placebo effects,” increased motivation for improvement, and increased compliance with treatment plans.3,6-8 Several studies have tried to assess the relationship of treatment expectations and outcome. Lutz et al9 found that patients that expected more rapid recovery with surgery for sciatica had similar functional outcomes but were more satisfied than patients who expected a slower recovery. In a randomized placebo-controlled trial of amitriptyline for chronic pain associated with spinal cord injuries, Turner et al8 found that patients with higher expectations of pain relief with amitriptyline had better symptom relief when they actually received amitriptyline but not when they received placebo. Similarly, in a randomized trial comparing massage therapy and acupuncture for low back pain, Kalauokalani et al10 found that patients who had higher expectations of benefit from the treatment they received had improved outcomes compared to those who were assigned to a treatment for which they had lower expectations. General optimism for improvement had no effect on outcome in that study. Perhaps most intriguingly, Iversen et al3 found that for patients undergoing surgery for spinal stenosis, those patients who had higher expectations for functional improvement with surgery had better functional outcomes and better satisfaction with their functional status after surgery, whereas those patients with higher expectations for pain relief from surgery had more pain and were less satisfied with their pain relief after surgery. Thus, although expectations seem to play a significant role in mediating some aspects of patient response to, and satisfaction with, treatment for low back pain, the details of this role remain unclear. Patient preferences for a certain treatment, which are related to, but distinct from, their expectations of the results of that treatment, may also play an important role in affecting treatment outcome. Understanding the therapeutic effects of patient preferences has been referred to as a “vital and formidable empirical task.”11 To better understand treatment preferences, outcomes expectations, and the relationship of these factors, we investigated baseline data from a large study comparing surgery and nonoperative treatment for patients with intervertebral disc herniation (IDH). We describe the baseline characteristics of patients with different treatment preferences and the relationship of specific expectations with those preferences. We hypothesized that expectations for various different aspects of treatment would be important drivers of treatment preference, and subjects with different preferences and expectations for surgery and nonoperative care would differ in clinically important ways that would need to be accounted for in any studies looking at the relationship of preference and expectations with outcome.