Reasons, perceived outcomes and characteristics of second-opinion seekers: are there differences in private vs. public settings?

Spine surgeons facing second opinions: a qualitative study

BACKGROUND CONTEXT

The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients.

PURPOSE

The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view.

STUDY DESIGN/SETTING

This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions.

PATIENT SAMPLE

We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared).

OUTCOME MEASURES

Themes and subthemes were analyzed using semistructured interviews until saturation was reached.

METHODS

Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon).

RESULTS

Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations).

CONCLUSIONS

The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.

Factors Affecting the Patient Journey in Scheduling a Specialist Appointment in a Public Healthcare System

A questionnaire was developed to evaluate the journey experienced by patients from identifying a need to see a community specialist in Israel's public healthcare system, through scheduling an appointment and attending. A telephone survey was conducted with a nationally representative group of 3751 adults, in 2019 to 2020. Fifty-seven percent needed to see a specialist in the last 6 months; among those, 82%, visited a specialist. Among the 3% who did not make an appointment, in 41 of 52 (79%) cases this was due to long waiting time. Younger and more educated patients were more likely to try to get an earlier appointment. Timeliness (55%) and wanting a specific physician (43%) were major considerations in scheduling. Reported need was greater in females, Jewish versus Arab respondents, more educated and those with chronic illness. Those who did not make an appointment sought private care, emergency treatment, or went untreated. Although a large percentage of respondents did eventually get an appointment, vulnerable patients may have more difficulty navigating the system. Following the patient journey can provide insights to help design services better suited to patients’ needs.

Effect of a discordant opinion offered by a second opinion physician on the patient's decision for management of spinal disc disease

BACKGROUND

Factors that influence a patient's decision for spinal surgery and selection of the spine surgeon have not been studied in the context of a Second Opinion (SO). Providing insight into these factors will guide surgeons in their discussion of treatment options with patients.

OBJECTIVE

This study aims to assess the impact of a discordant SO on the final decision of patients as compared to their initial preference regarding spinal disc disease treatment for chronic neck and low back pain.

PATIENT INVOLVEMENT

Patients in this study engage in clinical vignettes designed to induce decisional conflict.

METHODS

A cross-sectional study using clinical vignette-based questionnaires was presented to patients at the Family Medicine, Orthopedic, and Neurosurgery clinics at a university-based tertiary academic medical center.

RESULTS

A total of 246 patients participated in the study (response rate, 66.8%). Irrespective of the initial offered treatment, most patients wanted to consult a SO (64.2%). Most patients preferred conservative treatment to surgery after getting the initial recommendation (78.5%) and after getting a discordant SO (56.5%). There was an association between the agreement of the patient with the initial recommendation and the effect of the SO on the final decision of patients (p < 0.001). Patients who disagreed with the initially offered treatment were more likely to abide by their initial decision after the SO (80.8%) as compared to those who were in agreement (17.7%), while those who agreed with the initially offered treatment were more likely to change their decision (39.5%) or to take a third opinion (42.9%).

DISCUSSION

A discordant SO may validate patients' wishes when they disagree with the initially offered treatment and may lead to confusion when they agree with the initial physicians' recommendations.

PRACTICAL VALUE

As patients tend to abide by their initial preference, physicians should explicitly consider patients' wishes when discussing options for management of spinal disc disease.

Patient-initiated second medical consultations-patient characteristics and motivating factors, impact on care and satisfaction: a systematic review

OBJECTIVES

To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction and cost effectiveness.

DATA SOURCES

Embase, Medline, PsycINFO and Health Management Information Consortium (HMIC) databases.

STUDY DESIGN

A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

DATA COLLECTION/EXTRACTION METHODS

We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions.

PRINCIPAL FINDINGS

Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.

CONCLUSIONS

This review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

Outcomes of second opinions in general internal medicine

BACKGROUND

To date, the outcomes of second opinions in internal medicine in terms of diagnostic yield and patient benefit have not been studied extensively. This retrospective study explores the outcomes of second opinions at a general internal medicine outpatient clinic in an academic hospital.

METHODS

A register of all patients referred to the general internal medicine outpatient clinic of the University Medical Center in Utrecht for a second opinion, was kept. All 173 patients referred between June 2016 and August 2018 were selected. Case records were analyzed for patient characteristics, referring doctor, chief complaint, performed investigations, follow-up time and, established diagnosis, additional diagnoses, initiated treatment and reported benefit.

RESULTS

A new diagnosis was established in 13% of all patients. A new treatment was initiated in 56% of all patients: 91% and 51% of patients with and without a new diagnosis respectively (p < 0.001). Of all patients, 19% received an effective treatment (52% vs 14% of patients with vs without a new diagnosis, p < 0.001). Regardless of treatment, resolution or improvement of the chief complaint was achieved in 28% of all patients (52% vs 25% of patients with vs without a new diagnosis, p = 0.006). Regarding diagnostics, 23-33% of radiology, endoscopy and pathology tests performed during second opinion were a repetition of previously conducted investigations. Conventional blood tests were a repetition in 89% of cases. Median time to diagnosis was 64 days (IQR: 25-128 days) and median time to discharge was 75 days (IQR: 31-144 days).

CONCLUSION

Second opinions in general internal medicine lead to the establishment of a new diagnosis in a small proportion of patients. However, the value of second opinions may not be limited to the establishment of diagnoses, as new treatments are often initiated and overall patients report improved symptomatology in 28% of cases.

Effect of time interval from diagnosis to treatment for cervical cancer on survival: A nationwide cohort study

Objectives

Despite the ease of health care access and the waiver of copayments for cancer patients, treatment is delayed in a small proportion of Taiwanese patients diagnosed with cervical cancer. In this study, we explored the relationship between the time interval from diagnosis to treatment and survival in cervical cancer patients.

Material and methods

The study was a retrospective population-based observational study conducted between 2004 and 2010. In Taiwan, 12,020 patients were newly diagnosed with cervical cancer from 2004 to 2010, and 9,693 patients (80.6%) were enrolled in our final analysis.

Results

Most of the patients received treatment within 90 days of diagnosis (n = 9,341, 96.37%). After adjustment for other variables, patients who received treatment between 90 and 180 days and >180 days after diagnosis had a 1.33 (95% CI: 1.02–1.72, P < 0.05) and 1.36 (95% CI: 1.12–1.65, P < 0.05) times higher risk of death, respectively, than those who received treatment within 90 days. Kaplan–Meier analysis showed that the patients treated after 90 days from diagnosis had a lower overall survival rate than those treated within 90 days. In analysis stratifying the patients according to their initial tumor stage, namely stages I and II and stage III and IV, the time interval from diagnosis to treatment remained a significant prognosticator in those who received treatment >180 days after diagnosis.

Conclusion

A longer interval between diagnosis and treatment is associated with poorer prognosis among cervical cancer patients.

Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study

OBJECTIVES

To evaluate the utilisation (overall and by specialty) and the characteristics of second-opinion seekers by insurance type (either health fund or supplementary insurance) in a mixed private-public healthcare.

DESIGN

An observational study.

SETTING

Secondary care visits provided by a large public health fund and a large supplementary health insurance in Israel.

PARTICIPANTS

The entire sample included 1 392 907 patients aged 21 years and above who visited at least one specialist over an 18 months period, either in the secondary care or privately via the supplementary insurance.

OUTCOMES MEASURES

An algorithm was developed to identify potential second-opinion instances in the dataset using visits and claims data. Multivariate logistic regression was used to identify characteristics of second-opinion seekers by the type of insurance they used.

RESULTS

143 371 (13%) out of 1 080 892 patients who had supplementary insurance sought a single second opinion, mostly from orthopaedic surgeons. Relatively to patients who sought second opinion via the supplementary insurance, second-opinion seekers via the health fund tended to be females (OR=1.2, 95% CI 1.17 to 1.23), of age 40-59 years (OR=1.36, 95% CI 1.31 to 1.42) and with chronic conditions (OR=1.13, 95% CI 1.08 to 1.18). In contrast, second-opinion seekers via the supplementary insurance tended to be native-born and established immigrants (OR=0.79, 95% CI 0.76 to 0.84), in a high socioeconomic level (OR=0.39, 95% CI 0.37 to 0. 4) and living in central areas (OR=0.88, 95% CI 0.85 to 0.9).

CONCLUSIONS

Certain patient profiles tended to seek second opinions via the supplementary insurance more than others. People from the centre of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas. Further research is recommended to examine the availability of medical specialists by specialty and residence.