NASS News: Great Expectations vs. Greater Expectations

Eighty-six percent of lumbar spine surgery patients had greater expectations for their own improvement after lumbar surgery than their surgeons had, according to new research reported today at the North American Spine Society’s (NASS) 2017 Annual Meeting in Orlando, Fla. Two years and a post-surgery survey later, it turned out the surgeons were much better at predicting actual improvement than their patients.

“While it is hardly surprising that spine surgeons are better able to accurately predict surgical outcomes, it is the degree to which the predictions diverged that is significant,” said Carol A. Mancuso, M.D., senior scientiest at the Hospital for Special Surgery, and lead study author. “Evidently, surgeons and patients need to do a better job of working together to candidly communicate realistic expectations throughout the pre-operative and post-operative processes.”

The study, “Surgeons’ Preoperative Expectations Predict Fulfillment of Patients’ Expectations Two Years After Lumbar Surgery,” is a prospective, two-year longitudinal study of 164 lumbar surgery patients and their surgeons at a tertiary spine center.

Patients of five spine surgeons were interviewed pre-operatively with the Expectations Survey, a valid 20-item survey addressing symptoms, physical function, and psychological well-being. The survey asks how much improvement is expected for each item with response options of complete to no improvement and a total score is generated (range 0-100, higher=greater expectations). Surgeons completed an identical survey asking them to rate expected improvement for each item for each patient, yielding a similar 0-100 score. Concordance within the patient-surgeon pair was measured with the intraclass correlation coefficient (ICC) (range 0=agreement no better than chance to 1=perfect agreement). Two years post-operatively, patients completed the survey again asking how much improvement they actually received for each item with options ranging from complete to no improvement. A “patient proportion” reflecting expectations fulfilled was calculated as the total improvement received (numerator) divided by the total improvement expected (denominator); range 0 (no improvement for any item) to 1 (improved as expected) to >1 (improved more than expected); the minimum clinically important (MCI) proportion was previously shown to be .60. A similar “surgeon proportion” was calculated using surgeons’ improvement expected as the denominator. Proportions were then compared using paired t-tests.

The mean age was 54, 52 percent were men, 84 percent had degenerative conditions. Patients and surgeons independently completed the survey within 10 days pre-operatively; patients completed the post-operative survey after 2.1 years. The mean pre-operative survey score was 74 for patients and 58 for surgeons (p<.0001), and the ICC was .36 (i.e., fair agreement). Eighty-six percent of patients had higher scores (i.e., greater expectations) than their surgeons. The post-operative version of the survey measured patients' reports of actual improvement received for each item. The proportion of expectations fulfilled (actual divided by expected improvement) was .75±.37 for patients and .94±.41 for surgeons (p<.0001). The proportion was perfect (≥1) for 27 percent of patients' and 53 percent of surgeons' ratings, and was greater than an MCI proportion (i.e.,≥.60) for 67 percent and 79 percent respectively, (p<.0001 for both comparisons). 

The researchers concluded that most patients had greater expectations than their surgeons and two-thirds met an MCI fulfillment of expectations. Surgeons’ expectations more closely approximated actual improvement with surgeons successfully predicting two-year fulfillment of expectations more often. These findings have potential implications for clinical practice including ensuring patients retain surgeons’ counsel about expectations throughout the pre-operative process; deciding whether an MCI proportion is sufficient success; and considering whether surgeons’ accurate predictions of patient-reported outcomes are potential measures of quality of care.

The study authors are: Carol A. Mancuso, M.D.; Roland Duculan, M.D.; Frank P. Cammisa, M.D.; Andrew A. Sama, M.D.; Alexander P. Hughes, M.D.; Darren R. Lebl, M.D.; Federico P. Girardi M.D.; from the Hospital for Special Surgery in New York, N.Y.

More than 3,000 spine professionals are meeting at the NASS 2017 Annual Meeting to share the latest information, innovative techniques and procedures, best practices, and new technologies in the spine field. NASS is a multidisciplinary medical organization that fosters high-quality, evidence-based, ethical spine care by promoting education, research, and advocacy. NASS is comprised of more than 8,000 members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, neurology, radiology anesthesiology, research, and physical therapy.