Patient satisfaction in the cervical spine research society outcomes study: relationship to improved clinical outcome

Google Search Analytics for Lateral Epicondylitis

BACKGROUND

The use of online search engines for health information is becoming common practice. We analyzed Google search queries to identify the most frequently asked topics and questions related to lateral epicondylitis ("tennis elbow") and the Web sites provided to address these questions.

METHODS

Four search terms for lateral epicondylitis were entered into Google Web Search. A list of the most frequently asked questions along with their associated Web sites was extracted and categorized by 2 independent reviewers.

RESULTS

A total of 400 questions were extracted with 168 associated Web sites. The most popular question topics were related to indications/management (39.0%), risks/complications (19.5%), and the ability to perform specific activities (18.8%). Frequently asked questions had to do with the duration of symptoms, self-management strategies (eg, brace use and self-massage), and the indications for surgery. The most common Web sites provided to address these questions were social media (27.5%), commercial (24.5%), academic (16.5%), and medical practice (16.3%).

CONCLUSION

The most frequently asked questions about lateral epicondylitis on Google centered around symptom duration and management, with most information originating from social media and commercial Web sites. Our data can be used to anticipate patient concerns and set expectations regarding the prognosis and management of lateral epicondylitis.

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery

BACKGROUND CONTEXT

Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse.

PURPOSE

The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores.

PATIENT SAMPLE

Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

OUTCOME MEASURES

PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience.

METHODS

Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores.

RESULTS

Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all).

CONCLUSIONS

In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

The Relation of Patient Expectations, Satisfaction, and Outcome in Surgery of the Cervical Spine: A Prospective Study

STUDY DESIGN

We performed a prospective nonblinded single center observational study.

OBJECTIVE

To investigate the relationship between expectations, outcome, and satisfaction with the outcome in patients undergoing cervical spine stabilization surgery.

SUMMARY OF BACKGROUND DATA

In modern healthcare, patient-reported outcome measures and patient satisfaction have become an important aspect of quality control. Therefore, outcome benchmarks for specific diseases are highly desired. Numerous studies have investigated patient-reported outcome measures and what constitutes satisfaction in degenerative lumbar spine disease. In cervical spine surgery, it is less clear what drives the postoperative symptom burden and patient satisfaction and how this depends on the primary diagnosis and other patient factors.

METHODS

This was a prospective, single center, observational study on patients undergoing cervical spine stabilization surgery for degenerative disease, trauma, infection, or tumor. Using the visual analogue scale for neck and arm pain, the neck disability index (NDI), the modified Japanese Orthopedic Association Score (mJOA) and patient-reported satisfaction, patient status and expectations before surgery, at discharge, 6 and 12 months after surgery were evaluated.

RESULTS

One hundred five patients were included. Score-based outcome correlated well with satisfaction at 6 and 12 months. Except for low NDI expectations (≥15 points) that correlated with dissatisfaction, expectations in no other score were correlated with satisfaction. Expectations did influence the outcome in some subgroups and meeting expectations resulted in higher rates of satisfaction. Pain reduction plays an important role for satisfaction, independently from the predominant symptom or pathology.

CONCLUSION

Satisfaction correlates well with outcome. Meeting expectations did influence satisfaction with the outcome. The NDI seems to be a valuable preoperative screening tool for poor satisfaction at 12 months. In degenerative pathology, pain is the predominant variable influencing satisfaction independently from the predominant symptom (including myelopathy).

LEVEL OF EVIDENCE

5.

Using the cobweb classification system as a digital location system for the neurologic compression in cervical degenerative disease

OBJECTIVE

To provide the cobweb classification system (CCS) for the precise digital location and description of the neurological compression in cervical degenerative disease (CDD), and the reliability and the clinical subgroup analysis of the system were tested and analyzed.

METHODS

The CCS consisted of three parts: compression zones (1-12), degrees (a, b) and ossification (s, m, h). Computerized tomography (CT) and magnetic resonance imaging (MRI) images from 238 CDD patients were reviewed. All compression cases were classified by five independent reviewers with varied clinical experience in spine surgery. The reliability of the CCS was tested by calculating the kappa (κ) statistics value. Finally, 74 patients with anterior cervical surgery treatment were enrolled for the clinical subgroup analysis.

RESULTS

For the small compression, including single and double compression zones, there was a good interobserver reliability between the reviewers (κ coefficient = .855, P < .001). For the large compression with three or more involved zones, there was a fair reliability between the reviewers (κ coefficient = .696, P < .001). The whole intraobserver reliability was good (κ coefficient = .923, P < .001). For clinical practice, the operative time in the large compression and the m/h group was significantly longer than the small compression and the s group, respectively (P < .05), and the blood loss in the m/h group was significantly increased as well (P < .01). Though the preoperative Japanese Orthopedic Association score in Group b was lower than Group a (P < .05), all patients had achieved significant clinical improvement at last follow-up.

CONCLUSIONS

The CCS can be used to provide detailed and objective descriptions of the location, extent, and severity of neurological compressions in CDD with satisfactory reliability. Surgeons should pay more attention to the patient with large zone, degree b, and ossification compression, because the operation may be more challenging.

Clinically Meaningful Improvement Following Cervical Spine Surgery: 30% Reduction Versus Absolute Point-change MCID Values

STUDY DESIGN

Retrospective analysis of prospectively collected registry data.

OBJECTIVE

The aim of this study was to compare the performance of 30% reduction to established absolute point-change values for measures of disability and pain in patients undergoing elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Recent studies recommend using a proportional change from baseline instead of an absolute point-change value to define minimum clinically important difference (MCID).

METHODS

Analyses included 13,179 patients who underwent cervical spine surgery for degenerative disease between April 2013 and February 2018. Participants completed a baseline and 12-month follow-up assessment that included questionnaires to assess disability (Neck Disability Index [NDI]), neck and arm pain (Numeric Rating Scale [NRS-NP/AP], and satisfaction [NASS scale]). Participants were classified as met or not met 30% reduction from baseline in each of the respective measures. The 30% reduction in scores at 12 months was compared to a wide range of established absolute point-change MCID values using receiver-operating characteristic curves, area under the receiver-operating characteristic curve (AUROC), and logistic regression analyses. These analyses were conducted for the entire patient cohort, as well as for subgroups based on baseline severity and surgical approach.

RESULTS

Thirty percent reduction in NDI and NRS-NP/AP scores predicted satisfaction with more accuracy than absolute point-change values for the total population and ACDF and posterior fusion procedures (P < 0.05). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 16.8%) and bed-bound disability (ODI 81%-100%: 16.6%) categories. For pain, there was a 1.9% to 11% and 1.6% to 9.6% AUROC difference for no/mild neck and arm pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.

CONCLUSION

A 30% reduction from baseline is a valid method for determining MCID in disability and pain for patients undergoing cervical spine surgery.Level of Evidence: 3.

Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction and Return to Work After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

STUDY DESIGN

Retrospective review of prospectively-collected registry data.

OBJECTIVES

The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR).

SUMMARY OF BACKGROUND DATA

Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion.

METHODS

A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years.

RESULTS

In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery.

CONCLUSION

Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

The mediating role of patient satisfaction and perceived quality of healthcare in the emergency department

The purpose of this research was to identify whether a certain set of drivers of satisfaction/perceived quality of healthcare (PQHC) could indirectly affect patients' confidence/trust in the emergency department (ED).Patients were seen at an ED in the public hospital in Lisbon, Portugal between January and December 2016. Data were collected between May and November 2017, using a questionnaire, by mail or e-mail. The total sample size comprised 382 patients. The data analysis included structural equation modeling to test the conceptual model with specific drivers of satisfaction/PQHC (privacy; accessibility and availability; doctors; meeting expectations; waiting time for triage [perception]; waiting time to be called back by the doctor following examinations and/or tests [perception]; information about possible delays in receiving treatment/waiting times) and with the main outcome (confidence/trust in the ED) using path analysis.The analysis of the coefficients revealed that all the mediated paths are statistically significant (P ≤ .05). Although, altogether, the direct paths did not prove statistically significant (P > .05), the overall satisfaction with doctors (P ≤ .01) and meeting expectations (P = .01) can still directly explain the confidence/trust in the ED without the mediating role of satisfaction and PQHC. Hence, overall satisfaction with doctors and meeting expectations can influence, both directly and indirectly, confidence/trust in the ED. All other variables can only indirectly affect confidence/trust in the ED, either through PQHC or through satisfaction.Even though there are more variables that influence confidence/trust in the ED through PQHC (1)waiting time to be called back by the doctor following examinations and/or tests [perception]; 2) privacy; 3) accessibility and availability; 4) doctors; 5) meeting expectations than through satisfaction (1)waiting time for triage [perception]; 2) information about possible delays in receiving treatment/waiting times; 3) doctors; 4) meeting expectations), we observe the strongest contribution in the mediation model through satisfaction, which reveals its dominant role over PQHC.

Does Neck Disability Index Correlate With 12-Month Satisfaction After Elective Surgery for Cervical Radiculopathy? Results From a National Spine Registry

BACKGROUND

Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life.

OBJECTIVE

To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR.

METHODS

The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction.

RESULTS

The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score.

CONCLUSION

Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.

Patient Acceptability of the Use of Advanced Practice Providers in an Outpatient Neurosurgery Clinic

Introduction

Increasing demands for healthcare manpower has necessitated the utilization of advanced practice providers (APPs). The effect of APPs in primary care has been well-characterized but is less studied in surgical subspecialties. The objective of this study is to assess the patient acceptability of APPs in an outpatient neurosurgery setting.

Methods

We conducted a prospective, survey-based study among 78 adult patients in the neurosurgical outpatient clinic. The survey consisted of 10 questions assessing the hypothetical acceptability of care provided by neurosurgeons and APPs. These were compared as pre-specified dyads, with patients blinded to dyad composition. The data were analyzed with Chi-square tests.

Results

Patients preferred to see their neurosurgeon for their first clinic visit even with a longer lag time (29% acceptability difference, p = 0.012). Patients also preferred to see the neurosurgeon for their first postoperative visit (20% difference, p = 0.009). For all visits, patients preferred to see an APP if the clinic visit would be on time, rather than see the surgeon with a significant delay (30% difference, p = 0.0002). If their visit was scheduled with an APP, patients preferred that the neurosurgeon review their treatment plan before they left the clinic (15% difference, p = 0.04). Overall, seeing an APP was acceptable if patients were informed ahead of time (37% difference, p < 0.0001).

Conclusions

Team-based care utilizing APPs is acceptable to patients. Patients had strong preferences for seeing their surgeon for the first neurosurgical clinic visit and first post-operative visit. Patients were satisfied with seeing an APP if they could be seen more expeditiously. Patients also preferred to know ahead of time if they were going to see an APP.

Patient Satisfaction in Spine Surgery: A Systematic Review of the Literature

Patient satisfaction reflects the patients' perception of the outcome of care and is being considered for use in future reimbursement schemes. No consensus exists regarding the best instrument to measure patient satisfaction in the field of spine surgery. This systematic review aimed to determine how patient satisfaction for spine surgery has been measured previously and whether a disease-specific, comprehensive instrument to measure patient satisfaction has been established; we also aimed to define the dimensions of care that determine patient satisfaction in spine surgery. A systematic search of three online databases, unpublished sources, and citations was undertaken to identify 156 empirical studies that reported on patient satisfaction in the field of spine surgery. Manuscripts were reviewed in terms of the patient satisfaction instrument used, and the instruments were categorized as per content and method axes. Taxonomy of patient satisfaction with spine surgery identified the major characteristics of providers and medical care that influenced patient satisfaction and acted as a structure to categorically define the dimensions of patient satisfaction in spine surgery. The reviewed studies predominantly used global (108/156) rather than multidimensional (46/156), instruments. Most studies (96.2%) reported satisfaction with outcome rather than with care, and only 18.5% of the studies (29/156) utilized a disease-specific instrument. The following seven dimensions of patient status, outcome, and care experience that affected patient satisfaction were identified: pain, function, patient expectations/preference, specific patient health characteristics, caregiver interpersonal manner, efficacy/clinical outcomes, and postoperative care/therapy. Currently, no disease-specific instrument that includes all dimensions of patient satisfaction in spine surgery has been developed. Such a patient satisfaction instrument should be designed, tested for reliability and validity, and widely implemented.

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored.

METHODS

The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest.

RESULTS

We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001).

CONCLUSION

Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction.

LEVEL OF EVIDENCE

3.

Comparison of the Pain Sensitivity Questionnaire and the Pain Catastrophizing Scale in Predicting Postoperative Pain and Pain Chronicization After Spine Surgery

STUDY DESIGN

This was a prospective study evaluating the Pain Sensitivity Questionnaire (PSQ) in 110 patients undergoing spine surgery.

OBJECTIVE

The purpose of this study was to compare the ability of the PSQ-total and PSQ-minor scores with the Pain Catastrophizing Scale (PCS) in predicting the immediate postoperative pain of patients after spinal surgery and their risk of developing a chronically painful state.

SUMMARY OF BACKGROUND DATA

Studies evaluating the PSQ as a preoperative determinant for the development of chronic pain are lacking. Therefore, we undertook the following study.

MATERIALS AND METHODS

Patients undergoing lumbar or cervical spine surgery were prospectively included in the study. The PSQ-total and PSQ-minor, the PCS and its subscores, the Oswestry Disability Index (ODI) and the Neck Disability Index were used preoperatively. Preoperative and postoperative Visual Analog Scale scores for pain at rest and movement and analgesics were recorded. At 12 months postoperatively, the Neck Disability Index and the ODI were once more assessed to evaluate pain chronicization.

RESULTS

A total of 110 patients scheduled to undergo surgery at our spine center participated in the study. Our results highlighted that Visual Analog Scale scores were increased for high catastrophizers at rest on the first postoperative day when compared with low catastrophizers. Preoperative use of opioids and a high score on the rumination subscale of the PCS were linked to greater postoperative morphine consumption. At 12 months, the PCS, the PSQ-total, and PSQ-minor showed correlations with the development of a chronically painful state for ODI scores >21, indicating a marked persistent disability.

CONCLUSIONS

Both PSQ and PCS showed an ability to predict a chronically painful state as defined by the persistence of disability after lumbar surgery.

Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients

Background

Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain.

Methods

Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique.

Results

Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495).

Conclusions

This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Utility of percutaneous catheters for local anaesthetics infusion for postoperative pain control in lumbar arthrodesis. A prospective cohort study

OBJECTIVE

To evaluate whether postoperative continuous wound infiltration of levobupivacaine through two submuscular catheters connected to two elastomeric pumps after lumbar instrumented arthrodesis is more effective than intravenous patient-controlled analgesia.

MATERIAL AND METHODS

An observational, prospective cohorts study was carried out. The visual analogue scale, the need for additional rescue analgesia and the onset of adverse effects were recorded.

RESULTS

Pain records measured with visual analogue scale scale were significantly lower in the 48hours postoperative record at rest (p=.032). The other records of visual analogue scale showed a clear tendency to lower levels of pain in the group treated with the catheters. No statistically significant differences were found in the rescue analgesia demands of the patients. The adverse effects were lower in the catheter group (6 cases versus 11 cases) but without statistical differences.

CONCLUSIONS

A trend to lower pain records was found in the group treated with catheters, although differences were not statistically significant.

Effect of patients' functional status on satisfaction with outcomes 12 months after elective spine surgery for lumbar degenerative disease

BACKGROUND

Comprehensive assessment of quality of care includes patient-reported outcomes, safety of care delivered, and patient satisfaction. The impact of the patient-reported Oswestry Disability Index (ODI) scores at baseline and 12 months on satisfaction with outcomes following spine surgery is not well documented.

PURPOSE

This study aimed to determine the impact of patient disability (ODI) scores at baseline and 12 months on satisfaction with outcomes following surgery.

STUDY DESIGN

Analysis of prospectively collected longitudinal web-based multicenter data.

PATIENT SAMPLE

Patients undergoing elective surgery for degenerative lumbar disease were entered into a prospective multicenter registry.

OUTCOME MEASURES

Primary outcome measures were ODI, North American Spine Society satisfaction (NASS) questionnaire.

METHODS

Baseline and 12-month ODI scores were recorded. Satisfaction at 12 months after surgery was measured using NASS questionnaire. Multivariable proportional odds logistic regression analysis was conducted to determine the impact of baseline and 12-month ODI on satisfaction with outcomes.

RESULTS

Of the total 5,443 patients, 64% (n=3,460) were satisfied at a level where surgery met their expectations (NASS level 1) at 12 months after surgery. After adjusting for all baseline and surgery-specific variables, the 12-month ODI score had the highest impact (Wald χ²=1,555, 86% of the total χ²) on achieving satisfaction with outcomes compared with baseline ODI scores (Wald χ²=93, 5% of the total χ²). The level of satisfaction decreases with increasing 12-month ODI score. Greater change in ODI is required to achieve a better satisfaction level when the patient starts with a higher baseline ODI score.

CONCLUSION

Absolute 12-month ODI following surgery had a significant association on satisfaction with outcomes 12 months after surgery. Patients with higher baseline ODI required a larger change in ODI score to achieve satisfaction. No single measure can be used as a sole yardstick to measure quality of care after spine surgery. Satisfaction may be used in conjunction with baseline and 12-month ODI scores to provide an assessment of the quality of spine surgery provided in a patient centric fashion.

Patient Expectations and Preferences in the Spinal Surgery Clinic

BACKGROUND

Managing patient expectations is essential in the treatment of patients undergoing spinal surgery. Patient satisfaction is associated with improved clinical outcomes and can be improved when patient and surgeon expectations are aligned and patient preferences are met.

METHODS

Patients presenting to clinic for management of spinal disease were asked to complete a questionnaire assessing demographics, current pain, reason for visit, and expectations and preferences surrounding the clinic experience. Variables were compared with χ² tests to determine factors associated with patient expectations. Subsets of new patients and returning patients were compared by the use of matched pair tests. One-way analysis of variance was used to compare means of clinic expectations in patients depending on their level of education.

RESULTS

A total of 240 patients were included. New patient evaluation was the most common reason for evaluation (26.6%), and pain relief was the most common chief concern (39.3%). Patients preferred their surgeon wash their hands in the room instead of before entering (P < 0.001) and wear professional attire over scrubs (P < 0.001). Patients believe their wait time will be longer than it should be (P = 0.002), they will spend longer in clinic than they should (P = 0.03), and they will get less face-to-face time with their surgeon than they should (P < 0.01) but also that the surgeon is not getting paid enough for the clinic visit (P = 0.02).

CONCLUSIONS

Because spine surgery is largely elective, patients often seek treatment to improve quality of life and alleviate subjective symptoms. Understanding patient expectations is critical to ensure that patients and physicians are working toward similar goals.

Preoperative Depression, Smoking, and Employment Status are Significant Factors in Patient Satisfaction After Lumbar Spine Surgery

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To determine whether comorbidities and demographics, identified preoperatively, can impact patient outcomes and satisfaction after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

The surgical treatment of lower back pain does not always eliminate a patient's pain and symptoms. Revision surgeries are costly and expose the patient to additional risk. We aim to identify patient characteristics that may suggest a greater or lesser likelihood of postsurgical success by examining patient-reported measures and outcomes after surgery.

METHODS

Preoperative smoking status, self-reported depression, prevalence of diabetes, obesity, level of education, and employment status were assessed in the context of patient outcome and satisfaction after lumbar spine surgery. Patients were contacted before surgery, and at 3 and 12 months postoperatively, and responded to Oswestry Disability Index (ODI) and EuroQol-5 Dimensions (EQ-5D) self-assessment examinations, as well as a satisfaction measure.

RESULTS

A total of 166 patients who underwent lumbar spine surgeries at Iowa Spine and Brain Institute, a department of Covenant Medical Center, and were included in the National Neurosurgery Quality and Outcomes Database were assessed preoperatively, and at 3 and 12 months postoperatively using self-assessment tools. Depression, smoking, and employment status were found to be significant factors in patient satisfaction. Depressed patients, smokers, and patients on disability at the time of surgery have worse ODI and EQ-5D scores at all of the timepoints (baseline, 3 months, and 12 months postsurgery).

CONCLUSIONS

Depression, smoking, and employment status, specifically whether a patient is on disability at the time of surgery, are all significant factors in patient satisfaction after lumbar spine surgery. These factors are also shown in impact ODI and EQ-5D scores. Surgeons should consider these particular characteristics when developing a lower back pain treatment plan involving surgery.

Fulfillment of patients' expectations of lumbar and cervical spine surgery

BACKGROUND CONTEXT

Fulfillment of expectations is an important outcome of spine surgery.

PURPOSE

The study aimed to compare fulfillment of expectations after surgery with preoperatively stated expectations.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

The sample included patients who had lumbar and cervical spine surgeries.

OUTCOME MEASURES

The outcome measures were self-report valid surveys-[blinded] Lumbar Spine Surgery Expectations Survey and [blinded] Cervical Spine Surgery Expectations Survey-Oswestry Disability Index (ODI), and Neck Disability Index (NDI).

METHODS

Patients preoperatively completed a valid 20-item lumbar or cervical spine surgery Expectations Survey measuring the amount of improvement expected for symptoms, physical function, and mental well-being. Two years postoperatively, patients were asked about fulfillment of each expectation; a proportion was calculated as the amount of improvement received versus the amount of improvement expected. The proportion ranges from 0 (no expectations fulfilled) to 1 (all expectations fulfilled as expected), to >1 (expectations surpassed). Patients also completed the ODI or NDI, as well as questions about 2-year interval events, such as subsequent surgery.

RESULTS

Among the 366 patients who had lumbar surgery, 90% had at least some of their expectations fulfilled (15% expectations surpassed, 9% expectations fulfilled as expected, and 66% expectations fulfilled somewhat) and 10% had none of their expectations fulfilled; the mean proportion of expectations fulfilled was .66. In multivariable analysis, variables that were associated with a lower proportion of expectations fulfilled were more preoperative expectations, not working full-time, previous spine surgery, surgery for more vertebral levels, subsequent spine surgery, and less improvement in pre- to postoperative ODI and pain scores (p≤.05 for all variables). Among the 133 patients who had cervical surgery, 91% had at least some of their expectations fulfilled (23% expectations surpassed, 8% expectations fulfilled as expected, and 60% expectations fulfilled somewhat) and 9% had none of their expectations fulfilled; the mean proportion of expectations fulfilled was .78. In multivariable analysis, variables that were associated with a lower proportion of expectations fulfilled were more preoperative expectations and less improvement in pre- to postoperative NDI and pain scores (p≤.05 for all variables).

CONCLUSIONS

Fulfillment of expectations after spine surgery is associated with multiple pre- and postoperative variables, including the amount of improvement expected preoperatively.

Satisfaction With the Outcome of Physical Therapist-Prescribed Exercise in Chronic Whiplash-Associated Disorders: Secondary Analysis of a Randomized Clinical Trial

Study Design Secondary analysis of a randomized clinical trial. Background Patient perception of the benefits gained from treatment is important, yet satisfaction with the outcome of treatment for chronic whiplash-associated disorders (WADs) has not been investigated. Objectives To investigate whether satisfaction with the outcome of treatment for chronic WAD changed over time, and whether there were group differences. Methods Two hundred sixteen people with chronic WAD (66% women; mean age, 40.4 years) participated in a 3-month program of physical therapist-led neck-specific exercises with or without a behavioral approach, or received a prescription of general physical activity. The main outcome was satisfaction with the outcome of treatment, assessed at baseline and 3, 6, and 12 months later. Additional outcomes were enablement and expectation fulfillment. Results Satisfaction improved over time in the 3 groups (odds ratio = 1.15; 95% confidence interval: 1.10, 1.20; P<.001). There was a significant group-by-time interaction (P<.001), with increased odds of being satisfied in the groups receiving neck-specific exercises compared to general physical activity. Enablement increased after completion of the intervention in all groups (P<.001). People who received neck-specific exercises reported greater enablement and expectation fulfillment than people prescribed general physical activity (P<.01). Conclusion Exercise interventions for chronic WAD led to increased satisfaction for 12 months following treatment that was unrelated to the type of exercise intervention received. Level of Evidence Therapy, level 1b. Registered January 22, 2012 at www.ClinicalTrials.gov (NCT01528579). J Orthop Sports Phys Ther 2016;46(8):640-649. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6136.

Intrathecal morphine for postoperative pain control after laminoplasty in patients with cervical spondylotic myelopathy

OBJECTIVES

To examine the clinical efficacy of intrathecal morphine as postoperative analgesia for cervical laminoplasty.

SUMMARY OF BACKGROUND DATA

Patients who undergo posterior cervical spinal surgery frequently experience significant postoperative pain. Postoperative pain contributes to patient morbidity because of decreasing early voluntary mobilization and delayed rehabilitation. Intrathecal morphine is known to be a simple and effective analgesia. However, the effectiveness of intrathecal morphine for cervical spinal surgery has not yet been reported.

METHODS

Seventy-eight patients with cervical spondylotic myelopathy were divided into two groups prospectively, a diclofenac suppository (DS) group who received 50 mg diclofenac suppository at the end of the surgery, and an intrathecal morphine (ITM) group who were preoperatively administered 0.3 mg of morphine chloride, intrathecally, via a lumbar puncture. All patients underwent double-door laminoplasty of C3-6 or C3-7 level. Visual analog scale (VAS) of cervical pain, self-rating pain impression, supplemental analgesic usage, and complication rate were evaluated until the seventh postoperative day.

RESULTS

Thirty-one patients in the DS group and 32 patients in the ITM group were finally assessed. No baseline variable differences between the two groups were observed. The VAS was significantly lower in the ITM group at 4 h and 24 h until the seventh postoperative day. Self-rating pain impression was significantly better in the ITM group. No significant difference was observed in complication rate.

CONCLUSIONS

Intrathecal morphine was an effective and safe analgesic method for cervical laminoplasty in patients with cervical spondylotic myelopathy.

The Choice Between Total Hip Arthroplasty and Arthrodesis in Adolescent Patients: A Survey of Orthopedic Surgeons

For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.

Psychosocial factors and surgical outcomes: are elderly depressed patients less satisfied with surgery?

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVE

In this study, we set out to assess the effect of preoperative depression on patient satisfaction after revision lumbar surgery.

SUMMARY OF BACKGROUND DATA

Patient satisfaction ratings are increasingly being used in health care as a proxy for quality of care. In the elderly, affective disorders such as depression have been shown to influence patient-reported outcomes and self-interpretation of health status.

METHODS

A total of 69 patients aged 65 years or older undergoing revision neural decompression and instrumented fusion for same-level recurrent stenosis-associated back and leg pain were included in this study. Preoperative Zung self-rating depression score, comorbidities, and postoperative satisfaction with surgical care and outcome were assessed for all patients. Baseline and 2-year visual analogue scale (VAS)-leg pain, VAS-back pain, Oswestry Disability Index, Short Form-12 physical component score and Short Form-12 mental component score, as well as health-state utility (EuroQol 5D) were assessed. Factors associated with patient satisfaction after surgical procedures were assessed via multivariate logistic regression analysis.

RESULTS

Compared with baseline, there was a statistically significant improvement in VAS-back pain 2.76±2.73 (pseudarthrosis [1.94±2.81], adjacent segment disease [4.35±3.16]), same-level recurrent stenosis [2±2.23]), VAS-leg pain 2.66±4.12, (adjacent segment disease [2.24±4.46] and same-level recurrent stenosis [3±3.78]). Two-year Oswestry Disability Index improved after surgery for pseudarthrosis (4.05±7.65), adjacent segment disease (6±13.63) and same-level recurrent stenosis (4.54±5.97). In a multivariate logistical regression model, increasing preoperative Zung self-rating depression scale scores were independently associated with patient dissatisfaction 2 years after revision lumbar surgery, (P<0.001).

CONCLUSION

This study demonstrates that independent of surgical effectiveness, baseline depression influence patient satisfaction with health care, 2 years after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality of care should account for patients' baseline depression as a potential confounder especially in this age group.

LEVEL OF EVIDENCE

3.

Patients' expectations of cervical spine surgery

STUDY DESIGN

Cross-sectional analysis of patients' expectations of cervical spine surgery using the Hospital for Special Surgery Cervical Spine Surgery Expectations Survey (Expectations Survey).

OBJECTIVE

To preoperatively describe patients' long-term expectations of surgery in terms of demographic, clinical, and psychological characteristics.

SUMMARY OF BACKGROUND DATA

Although important components of patient-centered care, few studies have systematically considered patients' expectations of cervical spine surgery.

METHODS

Several days before surgery, 150 patients completed the Expectations Survey, which is composed of 20 physical and psychological items; scores range from 0 to 100, and higher scores reflect choosing more items and more improvement (i.e., more expectations). Patients completed additional questionnaires addressing demographic, psychological, and clinical status, including disability due to pain with the Neck Disability Index (NDI) and overall physical and mental health with the 12-item Short Form Health Survey.

RESULTS

Mean age was 54 years, and 61% were males. The most commonly chosen items were relieve neck (87%) and upper extremity (85%) pain, stop the spine condition from getting worse (97%), and remove the control the spine condition had on life (96%). Twenty-three percent of patients chose all 20 items, 39% chose 16 to 19 items, and 38% chose 15 or fewer items. In multivariate analysis, patients were more likely to choose more items if they were younger (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.0; P = 0.01), had worse NDI scores (OR = 6.5; 95% CI, 3.2-13.2; P < 0.0001), and had worse SF-12 Physical (OR = 1.9; 95% CI, 1.0-3.6; P = 0.05) and Mental Health scores (OR = 2.0; 95% CI, 1.1-3.6; P = 0.02). The Expectations Survey scores ranged from 10 to 100, and the mean score was 65 ± 24. In multivariate analysis, patients were more likely to have higher scores if they were younger (OR = 2.8; 95% CI, 1.4-6.0; P = 0.006) and had worse NDI scores (OR = 6.0; 95% CI, 2.8-13.2; P < 0.0001).

CONCLUSION

Multiple clinical variables were associated with expectations, with younger age and more disability due to pain being the most consistently associated with more expectations.

LEVEL OF EVIDENCE

3.

The Italian version of the Physical Therapy Patient Satisfaction Questionnaire - [PTPSQ-I(15)]: psychometric properties in a sample of inpatients

BACKGROUND

In a previous study we described the translation, cultural adaptation, and validation of the Italian version of the PTPSQ [PTPSQ-I(15)] in outpatients. To the authors' knowledge, the PTPSQ was never studied in a hospital setting.The aims of this study were: (1) to establish the psychometric properties of the Physical Therapy Patient Satisfaction Questionnaire [PTPSQ- I(15)] in a sample of Italian inpatients, and (2) to investigate the relationships between the characteristics of patients and physical therapists and the indicators of satisfaction.

METHODS

The PTPSQ-I(15) was administered to inpatients in a Physical Medicine and Rehabilitation Unit. Reliability of the PTPSQ-I(15) was measured by internal consistency (Cronbach's α) and test-retest stability (ICC 3,1). The internal structure was investigated by factor analysis. Divergent validity was measured by comparing the PTPSQ-I(15) with a Visual Analogue Scale (VAS) for pain and with a 5-point Likert-type scale evaluating the Global Perceived Effect (GPE) of the physical therapy treatment.

RESULTS

The PTPSQ-I(15) was administered to 148 inpatients, and 73 completed a second administration. The PTPSQ-I(15) showed high internal consistency (α = 0.949) and test-retest stability (ICC = 0.996). Divergent validity was moderate for the GPE (r = - 0.502, P < 0.001) and strong for the VAS (r = -0.17, P = 0.07). Factor analysis showed a one-factor structure.

CONCLUSIONS

The administration of PTPSQ-I(15) to inpatients demonstrated strong psychometric properties and its use can be recommended with Italian-speaking population. Further studies are suggested on the concurrent validity and on the psychometric properties of the PTPSQ-I(15) in different hospital settings or with other pathological conditions.

Preoperative Zung depression scale predicts patient satisfaction independent of the extent of improvement after revision lumbar surgery

BACKGROUND CONTEXT

Patient satisfaction ratings are increasingly being used in health care as a proxy for quality and are becoming the focal point for several quality improvement initiatives. Affective disorders, such as depression, have been shown to influence patient-reported outcomes and self-interpretation of health status. We hypothesize that patient psychiatric profiles influence reported satisfaction with care, independent of surgical effectiveness.

PURPOSE

To assess the predictive value of preoperative depression on patient satisfaction after revision surgery for same-level recurrent stenosis.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Fifty-three patients undergoing a revision surgery for symptomatic same-level recurrent stenosis.

OUTCOME MEASURES

Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health state values (EuroQol-5D [EQ-5D]), disability (Oswestry Disability Index [ODI]), pain (visual analog scale [VAS]), depression (Zung self-rating depression scale), and Short Form 12 (SF-12) physical and mental component scores (PCS and MCS). Patient satisfaction was dichotomized as either "YES" or "NO" on whether they were satisfied with their surgical outcome 2 years after the surgery.

METHODS

A total of fifty-three patients undergoing revision neural decompression and instrumented fusion for same-level recurrent stenosis-associated back and leg pain were included in this study. Preoperative Zung self-rating depression score (ZDS), education status, comorbidities, and postoperative satisfaction with surgical care and outcome was assessed for all patients. Baseline and 2-year VAS for leg pain (VAS-LP), VAS for low back pain (VAS-BP), ODI, SF-12 PCS and MCS, and health-state utility (EQ-5D) were assessed. Factors associated with patient satisfaction after surgery were assessed via multivariate logistic regression analysis.

RESULTS

Two years after surgery, a significant improvement was reported in all outcome measures: VAS-BP (5±2.94 vs. 9.28±1, p<.001), VAS-LP (3.43±2.95 vs. 9.5±0.93, p<.001), ODI (21.75±12.07 vs. 36.01±6, p<.001), SF-12 PCS (32.30±11.01 vs. 25.13±5.84, p<.001), SF-12 MCS (47.48±10.96 vs. 34.91±12.77, p<.001), EQ-5D (0.60±0.31 vs. 0.18±0.22, p<.001), and ZDS (37.52±11.98 vs. 49.90±10.88, p<.001). Independent of postoperative improvement in pain and disability (surgical effectiveness), increasing preoperative Zung depression score was significantly associated with patient dissatisfaction 2 years after revision lumbar surgery (Odds ratio=0.67 [confidence interval: 0.38, 0.87], p<.001).

CONCLUSIONS

Our study suggests that independent of the surgical effectiveness, the extent of preoperative depression influences the reported patient satisfaction after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality should account for the patients' baseline depression as potential confounders.

Development of an expectations survey for patients undergoing cervical spine surgery

STUDY DESIGN

Cross-sectional analysis of patient-reported preoperative data.

OBJECTIVE

To develop a valid and reliable patient-derived expectations survey for patients undergoing cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Measuring expectations is an important component in the assessment of patients undergoing cervical spine surgery. However, there currently are no uniform methods to measure expectations.

METHODS

This study was conducted in 3 phases. In phase 1, patients were queried with open-ended questions about what they expected as a result of surgery. Their responses were grouped into categories that became the items in the draft survey. During phase 2, another group of patients completed the draft survey twice to establish test-retest reliability. In phase 3, items were selected on the basis of concordance and clinical relevance and a scoring rubric was developed.

RESULTS

Phase 1: 25 patients with radiculopathy, myelopathy, or previous surgery with failed fusion (nonunion) (mean age, 55 yr, 44% women) volunteered 114 expectations from which 31 categories were discerned and became the items in the draft survey. Phase 2: another 25 patients completed the survey twice before surgery, a mean of 5 days apart. Phase 3: 21 items were retained for the final survey addressing pain, numbness, physical limitations, and psychological well-being. An overall score can be calculated ranging from 0 to 100 that incorporates number of items expected and degree of improvement expected. For patients in phase 2, scores for the first and second administrations were 58 and 57, Cronbach α coefficients were 0.90 and 0.93, and the intraclass correlation coefficient between scores was 0.90.

CONCLUSION

We developed a valid and reliable patient-derived expectations survey for patients undergoing cervical spine surgery that addresses expectations for physical and psychological well-being and generates an easy-to-interpret overall score. The survey can be used clinically and for research and fills a gap in the comprehensive preoperative assessment of patients undergoing cervical spine surgery.

Cross-cultural adaptation and validation of the Physical Therapy Outpatient Satisfaction Survey in an Italian musculoskeletal population

BACKGROUND

Although patient satisfaction is a relevant outcome measure for health care providers, few satisfaction questionnaires have been generally available to physical therapists or have been validated in an Italian population for use in the outpatient setting. The aim of this study was to translate, culturally adapt, and validate the Italian version of the Physical Therapy Outpatient Satisfaction Survey (PTOPS).

METHODS

The Italian version of the PTOPS (PTOPS-I) was developed through forward-backward translation, review, and field-testing a pre-final version. The reliability of the final questionnaire was measured by internal consistency and test-retest stability at 7 days. Factor analysis was also used to explore construct validity. Concurrent validity was measured by comparing PTOPS-I with a 5-point Likert-type scale measure assessing the Global Perceived Effect (GPE) of the treatment and with a Visual Analogue Scale (VAS).

RESULTS

354 outpatients completed the PTOPS-I, and 56 took the re-test. The internal consistency (Cronbach's alpha) of the original domains (Enhancers, Detractors, Location, and Cost) was 0.758 for Enhancers, 0.847 for Detractors, 0.885 for Location, and 0.706 for Cost. The test-retest stability (Intra-class Correlation Coefficients) was 0.769 for Enhancers, 0.893 for Detractors, 0.862 for Location, and 0.862 for Cost. The factor analysis of the Italian version revealed a structure into four domains, named Depersonalization, Inaccessibility, Ambience, and Cost. Concurrent validity with GPE was significantly demonstrated for all domains except Inaccessibility. Irrelevant or non-significant correlations were observed with VAS.

CONCLUSION

The PTOPS-I showed good psychometric properties. Its use can be suggested for Italian-speaking outpatients who receive physical therapy.

Patient expectations, outcomes and satisfaction: related, relevant or redundant?

STUDY DESIGN

 A prospective case series of patients undergoing lumbar spine surgery.

OBJECTIVE

 Is there a correlation between patients' expectations before lumbar surgery, postoperative outcomes, and satisfaction levels?

METHODS

 A prospective study of 145 patients undergoing primary, single-level surgery for degenerative lumbar conditions was conducted. Oswestry Disability Index, back Visual Analog Scale (VAS), and leg VAS were assessed preoperatively and at 6 weeks and 6 months after surgery. Patients' expectations were measured preoperatively by asking them to score the level of pain and disability that would be least acceptable for them to undergo surgery and be satisfied. Satisfaction was assessed 6 weeks postoperatively with a Likert scale. Differences in patient expectations between actual and expected improvements were quantified.

RESULTS

 Most patients had a clinically relevant improvement, but only about half achieved their expectations. Satisfaction did not correlate with preoperative pain or disability, or with patient expectation of improvement. Instead, satisfaction correlated with positive outcomes.

CONCLUSIONS

 Patient expectations have little bearing on final outcome and satisfaction. [Table: see text].

Heterogeneity in health status and the influence of patient characteristics across patients seeking musculoskeletal orthopaedic care - a cross-sectional study

Background

Health status is an important predictor of patient outcomes. Consequently, identifying patient predictors of health status is essential. In musculoskeletal orthopaedic care, the majority of work examining the association between patient characteristics and health status has been undertaken among hip/knee cohorts. We investigate these associations comparing findings across four musculoskeletal cohorts (hip/knee; foot/ankle; neck/back; elbow/shoulder).

Methods

Patients seeking elective musculoskeletal orthopaedic care were recruited prior to consultation. Questionnaires captured health domain status (bodily pain, physical functioning, and mental and general health) and covariates: demographics; socioeconomic characteristics; and comorbidity. Scores were compared across cohorts. Two path regression analyses were undertaken. First, domain scores were simultaneously examined as dependent variables in the overall sample. Subsequently, the model was assessed stratified by cohort.

Results

1,948 patients: 454 neck/back, 767 hip/knee, 378 shoulder/elbow, 349 foot/ankle. From stratified analyses, significant variability in covariate effects was observed. Worse bodily pain scores were associated with increasing age and female sex among hip/knee, low income among foot/ankle, and overweight/obese for foot/ankle and hip/knee. Worse mental health scores were associated with low income across cohorts except elbow/shoulder, low education within neck/back, and compared to Whites, Blacks had significantly worse scores among foot/ankle, better scores among hip/knee. Worse general health scores were observed for Asians among hip/knee, Blacks among foot/ankle, and South-Asians among elbow/shoulder and neck/back.

Conclusion

The substantial heterogeneity across musculoskeletal cohorts suggests that patient- and cohort-specific approaches to patient counsel and care may be more effective for achieving optimal health and outcomes.

Effect on clinical outcomes of patient pain expectancies and preoperative Mental Component Summary scores from the 36-Item Short Form Health Survey following anterior cervical discectomy and fusion

Object

The primary purpose of this study was to analyze what effect preoperative patient expectations and 36-Item Short Form Health Survey (SF-36) Mental Component Summary (MCS) scores have on clinical outcomes. To the authors' knowledge, there are no prospective studies that have examined the effects of both preoperative pain expectations and SF-36 MCS scores on clinical outcomes and satisfaction with results following anterior cervical discectomy and fusion (ACDF).

Methods

This study analyzed 79 patients (38 men, 41 women) undergoing 1- to 3-level ACDF surgery. Preoperatively, patients were divided into 2 groups for the expectation analyses: patients who expected complete resolution of pain postoperatively (44 total) and those who expected some residual pain (35 total) postoperatively. Preoperative SF-36 MCS scores were used to test the possible effects of mental health on clinical outcomes and satisfaction. Clinical outcomes were evaluated using visual analog scales (VASs) for neck/arm pain, Neck Disability Index (NDI), SF-36 Physical Component Summary (PCS)/MCS, and patient satisfaction with results scales. The mean follow-up duration was 38.8 months (range 7–59 months).

Results

All postoperative measures depicted significant improvement overall. Patients who expected no pain reported lower postoperative neck/arm pain scores (p < 0.02), higher SF-36 MCS scores (p = 0.04), and higher satisfaction with results scores (p = 0.01) compared with patients who expected some pain, after controlling for their respective preoperative scores. Higher preoperative SF-36 MCS scores predicted significantly lower postoperative neck pain (p = 0.003) and NDI (p = 0.004) scores, as well as higher postoperative SF-36 PCS (p = 0.002), SF-36 MCS (p = 0.001), and satisfaction (p = 0.03) scores, after controlling for their respective preoperative scores.

Conclusions

Patients who expected no pain postoperatively reported better scores on the nonstandardized outcome measure scales (VAS arm/neck, satisfaction with results), and higher SF-36 MCS scores. Higher preoperative MCS scores were related to better overall (standardized and nonstandardized) clinical outcomes (VAS neck, NDI, SF-36 PCS/MCS, and satisfaction with results). The results suggest that optimism in patients' expectations as well as mental well-being are related to improved clinical outcomes and higher patient satisfaction.

Measuring patient satisfaction following epilepsy surgery

PURPOSE

To systematically review primary research examining patient satisfaction with epilepsy surgery in order to obtain evidence-based estimates of this surgical outcome; to assess methods used to measure epilepsy surgery satisfaction, overall epilepsy surgery satisfaction ratings, and predictors of epilepsy surgery satisfaction.

METHODS

Systematic review of published studies in English up to June 2009, focusing on patient satisfaction with all types of epilepsy surgery in patients of all ages. We excluded studies that focused on satisfaction with epilepsy treatment in general, on quality of life without specific exploration of patient satisfaction with surgery, and on satisfaction with the process of health care delivery, rather than with surgery and its outcomes.

KEY FINDINGS

Eight studies met inclusion criteria. Satisfaction was assessed using one or more global questions. Four epilepsy surgery satisfaction question content patterns emerged: (1) satisfied or dissatisfied, (2) perceived success or failure, (3) overall positive or negative impact, and (4) willingness to repeat surgery or regretting surgery. Overall 71% were satisfied; 64% considered it a success; it had a positive effect for 78%; and 87% would repeat surgery. Seizure freedom was the most common predictor of epilepsy surgery satisfaction, whereas postoperative neurologic deficit predicted dissatisfaction.

SIGNIFICANCE

Patient satisfaction with interventions is an important aspect of patient-centered care, but it has received little attention in epilepsy surgery. Future research is required to develop and validate epilepsy surgery satisfaction tools. We provide preliminary guiding principles for measuring satisfaction after epilepsy surgery.

Forging convictions: the effects of active participation in a clinical trial

This qualitative study explored non-specific influences on participation in, and outcomes of, a randomised controlled trial. It was nested within a single-blind clinical trial of western acupuncture which compared real acupuncture with two types of placebo control administered to National Health Service (NHS) patients awaiting hip and knee replacement surgery in England. Data collection (2004-2008) was based on narrative-style interviews and participant observation. The results indicate that trial recruitment and retention depend on a set of convictions forged largely as a result of contextual factors peripheral to the intervention, including the friendliness and helpfulness of research centre staff and status of the administering practitioner. These convictions also influence the reporting of the study outcomes, particularly if participants experience uncertainties when choosing an appropriate response. The findings suggest that participants in clinical trials are actively involved in shaping the research process, rather than passive recipients of treatment. Thus the outcomes of trials, notably those involving contact interventions, should be regarded not as matters of fact, but as products of complex environmental, social, interpretive and biological processes. In this paper, we develop and present a 'theory of active research participation' which offers a framework for understanding the impact of non-specific processes in clinical trials.

Measuring patient satisfaction with exercise therapy for knee osteoarthritis: evaluating the utility of the physiotherapy outpatient survey

OBJECTIVES

To assess patient satisfaction with exercise for knee osteoarthritis (OA).

METHODS

A convenience sample of 27 patients recruited to a randomized controlled trial (RCT) comparing open kinetic chain and closed kinetic chain exercises for knee OA were reassessed at nine months post-randomization. Clinical outcomes included self-report and physical performance measures of function and pain severity. Patients also completed the Physiotherapy Outpatient Survey (POPS), which is a multi-dimensional measure of patient satisfaction with physiotherapy.

RESULTS

There was no significant difference in satisfaction between the two intervention groups. Overall mean satisfaction for the entire cohort was 4.07 of a maximum score of 5 (standard deviation (SD) = 0.52). Lower levels of satisfaction with outcome (mean = 3.56, SD = 0.8) were reported compared with other domains of expectations, communication, organization and the therapist (mean = 3.79-4.49; SDs = 0.42-0.92). Both intervention groups improved from baseline on clinical outcomes of pain, self-report function and walking distance, with no significant differences between the two groups.

CONCLUSIONS

High levels of satisfaction were reported in this subsample of knee OA patients participating in an RCT evaluating the effects of different exercise approaches for knee OA. Satisfaction varied depending on the satisfaction domain, with lower satisfaction with outcome compared with other aspects of care. The POPS questionnaire can be used to measure the multi-dimensional aspects of satisfaction with physiotherapy.

Relation between patient satisfaction, compliance and the clinical benefit of a teletreatment application for chronic pain

We investigated the ease of use and usefulness as a measure of patient satisfaction, compliance, clinical benefit and its mutual relationships concerning a teletreatment application for chronic pain. Fifty-two subjects with neck and shoulder pain received and completed a four-week myofeedback-based teletreatment intervention. Prior to the onset of the intervention (at baseline) and immediately after the intervention they were asked to fill in questionnaires to measure discrepancies (gap scores) between expectations and experiences with the ease of use and usefulness of the treatment, as well as pain intensity and pain disability. In addition, the actual use of the system (i.e. the volume of muscle activity data available on the server) was logged. The subjects reported a significantly higher score on ease of use after the intervention compared to baseline, suggesting that the equipment was easier to use than they expected. Compliance was associated with clinical benefit. There was no significant relation between patient satisfaction and compliance. Patient satisfaction is a key indicator of how well the telemedicine treatment met expectations and compliance is important because of its association with clinical outcomes.

The relationship between patient satisfaction with physical therapy care and global rating of change reported by patients receiving worker's compensation

This study examined relationships between patient satisfaction with physical therapy care and global rating of change; 1,944 respondents completed the Medrisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MR-12) and a nine-point Global Rating of Change Scale (GROC) following a course of physical therapy for a work-related musculoskeletal problem. Ninety percent of all respondents reported being satisfied or very satisfied with their overall care, whereas 70.1% of all respondents indicated they improved following treatment. Respondents who reported improvement had significantly higher scores for all measures of satisfaction (p<0.01) than did those who reported failure to improve; however, both of these groups had mean scores of greater than 4.0 on the MR-12, indicating that respondents were likely to be satisfied or very satisfied with care regardless of perceived change following treatment. Scores>4.0 from the MR-12 had high sensitivity to detect those respondents classified as "improved" (0.87-0.95), but low specificity to differentiate between those who were classified as "improved" and those who were classified as "did not improve" (0.22-0.30). Our findings support the hypothesis that patient satisfaction with care is primarily independent of perceived clinical change.

Postoperative continuous paravertebral anesthetic infusion for pain control in posterior cervical spine surgery: a case-control study

INTRODUCTION

Patients who undergo posterior cervical spinal fusion procedures frequently experience significant postoperative pain. Use of a local anesthetic continuous infusion pump after surgery may improve these outcome variables.

METHODS

After posterior cervical spine fusion procedures, 25 consecutive patients received continuous infusion of 0.5% bupivacaine into the subfascial aspects of the wound via an elastomeric pump. Data were collected prospectively by third party assessment using standard nursing protocols. This included numeric pain scores and opiate use over the first 4 postoperative days (PODs), length of hospitalization, and complications. In a retrospective analysis, we compared each study patient to a control patient who did not receive the continuous infusion of bupivacaine. Demographic variables and surgical procedure were similar among matched cases.

RESULTS

Patients receiving continuous local anesthetic infusion used significantly less narcotics (P < .05) during the first 4 PODs: 24.4% on day 1, 34.1% on day 2, 53.5% on day 3, and 58.1% on day 4. A lower average pain score was observed among study patients on each POD (P < .05): 31.5% less on day 1, 13.0% on day 2, 24.0% on day 3, and 35.7% on day 4. Patients with the infusion device were discharged home earlier (POD 4.9 versus 6.7; P = .024) and demonstrated improvement in time to ambulation, first bowel movement, and discontinuation of the patient-controlled analgesia machine. No complications were associated with the device.

CONCLUSION

Patients with the local anesthetic continuous infusion device required less narcotics and reported lower pain scores than control patients on each of the first 4 PODs. These results suggest that continuous infusion of local anesthetic into the paravertebral tissue during the immediate postoperative period is a safe and effective technique that achieves lower pain scores and narcotic use and improves multiple postoperative outcome variables.

Incidence of dysphagia comparing cervical arthroplasty and ACDF

STUDY DESIGN

Retrospective cohort from randomized prospective clinical trial.

OBJECTIVE

Evaluate incidence of dysphagia between instrumented ACDF and a no-profile cervical disc arthroplasty.

SUMMARY OF BACKGROUND DATA

Dysphagia is a well-known complication following anterior cervical discectomy and fusion (ACDF) and the etiology is multifactorial. One potential source for postoperative dysphagia involves the anterior profile of the implant used. Hence, a no-profile cervical disc arthroplasty could theoretically have fewer soft tissue adhesions and a lower incidence of dysphagia. The purpose of this study is to compare the incidence of dysphagia at least 1 year postoperatively following ACDF with anterior plating and a no-profile cervical disc arthroplasty.

METHODS

A cohort of 87 patients meeting the inclusion criteria for the prospective, randomized, multicenter IDE trial of ProDisc-C versus ACDF were evaluated for dysphagia. Forty-five patients were randomized to receive cervical arthroplasty and 42 patients were randomized to the ACDF and plate group. The Bazaz-Yoo dysphagia questionnaire was administered in a blinded fashion after completion of at least 12 months follow-up.

RESULTS

Follow-up averaged 18.2 months and included 76 (87%) of the 87 enrolled, with 38 of the original 45 in the arthroplasty group and 38 of the original 42 in the ACDF group. Six of 38 (15.8%) in the arthroplasty group versus 16 of 38 (42.1%) in the ACDF group reported ongoing dysphagia complaints. This was found to be statistically significant (P = .03).

CONCLUSION

This study suggests a significantly lower rate of dysphagia with a no-profile cervical disc arthroplasty compared to instrumented ACDF for single level disc disease between C3-7. Though there are many potential etiologies, we hypothesize this is related to the lack of anterior hardware in the retropharyngeal space. Operative technique, operating time, and significant midline retraction did not seem to result in more dysphagia complaints. Future studies comparing cervical disc arthroplasty and no-profile fusion devices may help delineate the effect that anterior instrumentation profile has on postoperative dysphagia.