Patient Preference Major Deciding Factor in Lumbar Disc Herniation Treatment
Posted Dec 01 2008 3:49pm
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Patients usually have expectations as to how treatment of a problem will work and how effective it will be. This is no different among patients who have lumbar intervertebral disc herniations, a bulging or slipped disk in the lumbar (lower) region of the back. These expectations can be harmful at times. If a patient has high expectations for results and the results are not as good as they expected, there is big disappointment and patient dissatisfaction. The reverse can also be true too, a sort of placebo effect. If a patient expects to feel better, there is a chance that he or she may feel better because it was expected.
Researchers have tried to understand how expectations are related to outcomes. In an attempt to understand, GK Lutz and colleagues found that patients who had surgery for sciatica and who expected a quick recovery had the same type of recovery as those who didn't have those expectations, but the first group of patients were more satisfied in the end. In another study, this time with patients who had pain from spinal cord injuries, JA Turner and colleagues found that if the patients expected good relief from their pain medication, they ended up with good pain relief. However, they didn't have the same effect with placebos.
In a different study involving patients who had spinal surgery for spinal stenosis, narrowing of the spinal canal, done by MD Iversen and colleagues had a bit of a different result. The researchers found that patients with high expectations of being able to move around again after surgery did have a better outcome and they were more satisfied with the results. But, patients who had high expectations for pain relief instead had more pain and they weren't as satisfied with the surgery.
Patient preference for treatment also appears to play a role in what may work and may not. The authors of this study wanted to find baseline characteristics of patients who had intervertebral disc herniation and who preferred certain treatment options over others. They then wanted to see if these preferences made a difference in the outcome.
The researchers reviewed 740 patients with the disc herniation. Their preferences were noted using a five-point scale of definitely nonsurgery, probably nonsurgery, not sure, probably surgery, or definitely surgery. They rated their expectations of the treatments for pain, swelling, numbness, weakness, and function. They were also asked about any expected harm from surgery. This five-point scale was: no chance, small chance, moderate chance, big chance, or certain. Function expectation was rated s expected benefit (surgery), expected harm (surgery), expected benefit (nonsurgery), and expected harm (nonsurgery).
The results of the study showed that more patients preferred to go the surgical route (67 percent) over nonsurgical (28 percent), with 6 percent being unsure of what they preferred. Those who preferred surgery were generally younger, had lower levels of education and high levels of unemployment. They also complained of more pain than the nonsurgery or unsure group, worse functioning (mental and physical), more pain-related disability, had had their pain for longer periods, and were more likely to be taking opioids, controlled drugs like morphine.
Although expecting higher complications with surgery, patient in the nonsurgical group said that both nonsurgery and surgery, equally, would be successful. Those who were unsure expected a greater benefit from surgery, while those who preferred surgery felt that nonsurgical care would be more harmful than surgery and that they had high expectations from the surgery.
There were many reasons why one approach was preferred over the other, including the desire to be able to continue working and participate in activities, which was the main reason for the surgery choice. Doctors' recommendations played a role in the decision but not more one way over the other. The researchers did find a significant influence was earlier experience with treatments that didn't involve surgery. Almost 20 percent of the group that preferred surgery stated that they had had previous nonsurgical treatment that was unsuccessful.
Overall, the authors of this article found that patient expectations do play a large role in how successful surgery or nonsurgery procedures turn out for spinal surgery. Those patients who wanted surgery were more adamant about their choices than the nonsurgical group. The authors pointed out that the group make-up may have something to do with this though. About 80 percent of the patients in the study were recruited by surgeons.
It was also noticed that patients who didn't want surgery were quite a distance away from being convinced that surgery may be better. They felt that the benefits of nonsurgical treatment far outweighed any risks that may result from surgery. Findings like these may help doctors understand why their patients choose specific treatments over others. In this case, patients who had high expectations of the benefits of nonsurgical treatment were convinced by these expectations. Therefore, it's important that patients be well assessed and informed about their benefits and risks so that they have all the necessary information to make the right decisions.
Jon D. Lurie, MD, MS, et al. Patient Preferences and Expectations for Care. Determinants in Patients with Lumbar Intervertebral Disc Herniation. In Spine. November 2008. Vol. 33, No. Pp. 2663-2668.