Low back pain is a prevalent medical condition afflicting primarily older adults but affecting all age groups and due to acute and non-acute diagnoses. Multiple possible conservative therapies exist;however, their major drawback is that the time required to advance therapy is often prolonged and accompanied by persistent disability and psychological suffering. Thus, some patients seek surgery after exhausting other therapies and some patients seek surgery earlier in their course. For both groups, decisions to undergo surgery are based on personal circumstances, perspectives, and expectations of outcome. Prior studies have shown that patients typically have high expectations of orthopedic surgery. Although high aspirations can be motivating, they also may predispose to poor outcomes if they are unrealistic and cause patients to become discouraged with recuperation time and ignore recommended lifestyle changes that avert progression of disease. Expectations that are too low, conversely, also may predispose to poor outcomes if patients lack motivation to participate in rehabilitation and to follow postop precautions. In order to achieve maximum benefit from surgery, patients and surgeons need to share an understanding of what is possible, probable, and realistic, and to join together and work toward the same goals. The primary objective of this proposed cross-sectional study is to assess the concordance between patients and their surgeons regarding expectations of lumbar spine surgery. Patients scheduled for lumbar surgery will be dichotomized according to whether they have acute versus non-acute conditions. Several days before surgery patients will complete the validated Lumbar Spine Surgery Expectations Survey measuring their physical and psychological expectations. Also before surgery their surgeons will complete the surgeon's version of the same survey for each patient. The main outcome will be a comparison of the concordance within each patient-surgeon pair according to acute versus non-acute groups based on the concordance correlation coefficient. Multivariate regression analysis based on the GEE method will be used to assess covariates. The secondary objective is to assemble a classroom and web-based curriculum that can be incorporated into existing infrastructures to instruct patients about expectations. The effectiveness of the curriculum in achieving greater concordance between patients and surgeons will be tested in a subsequent RCT. This R03 study builds on the investigative team's extensive experience studying patients'expectations and leverages a large volume of patients and an established methodology. This study will independently contribute to our understanding of patients'expectations and at the same time will provide the foundation for future interventional studies. Finally, this study maps to AHRQ's comparative effectiveness initiatives by addressing salient patient-centered issues for costly surgical procedures whose indications are not precisely defined. In addition, this study will be carried out in an urban setting and will address broad concepts of healthcare quality in conditions that primarily affect older adults.

Public Health Relevance

Patients seek spine surgery for low back pain 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 that they can join together and work toward the same goals. The objectives of this study are to compare agreement within the patient-surgeon pair regarding expectations of surgery for low back pain and then use this information to develop educational programs about expectations that can be given to patients before surgery.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Small Research Grants (R03)
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Health Care Quality and Effectiveness Research (HQER)
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Zhan, Chunliu
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Hospital for Special Surgery
New York
United States
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