Documenting the Gap Between Expectations and Outcomes

A new study from a group of German researchers has helped to document the gap between patient expectations and outcomes. Specifically, the team gathered data for the “what and why” of symptoms following cervical spine surgery, as well as the foundational elements of patient satisfaction—and how these relate (or not) to the primary diagnosis and other patient variables.

Co-author Dr. Hanno Meyer, an attending neurosurgeon at the Technical University of Munich in Germany, told OTW, “In cervical spine surgery patients, the relation of patient expectations to patient-reported outcomes (PROMs) and satisfaction had not been investigated prior to this study.”

The researchers examined data from 105 patients who underwent cervical spine stabilization surgery: 64 for degenerative disease (38 cervical spondylotic myelopathy, 18 radiculopathy only, 8 instability/neck pain); 19 trauma; 11 neoplasm; 7 revision stabilization surgery (implant failure/non-fusion); and 4 infection.

The team used the following measures: the Visual Analogue Scale for neck and arm pain, the Neck Disability Index, the modified Japanese Orthopedic Association Score, patient-reported satisfaction, patient status and expectations before surgery, at discharge, and 6 and 12 months after surgery.

Postoperative satisfaction rates, the research team found, were:

• at discharge: 80.8%,
• 6 months post discharge: 72.6%,
• 12 months: 79.4%).

For degenerative pathologies, the research team documented lower satisfaction rates than in non-degenerative pathologies (62% vs. 91%).

Cervical spondylotic myelopathy patients had the lowest rate of satisfaction (47%) compared with the radiculopathy (87%) or instability/neck pain (83%) groups. Specifically, cervical spondylotic myelopathy patients reported significantly more neck pain.

Unsatisfied degenerative disease cervical patients, after 6 months, tended to be older than satisfied patients (67.4 vs. 60.1 years)—but this difference disappeared after 12 months.

Age did not appear to correlate with satisfaction rates in other cervical pathologies.

As for patient postop expectations, they were high:

• 67% had high Visual Analogue Scale 1 expectations for neck pain relief,
• 73% for arm pain.

Patient expectations for neck pain correlated with clinical outcome in the nondegenerative and traumatic disease subgroups.

Patient expectations for Neck Disability Index and the modified Japanese Orthopedic Association Score correlated with the outcome in all degenerative disease patients and the cervical spondylotic myelopathy subgroup.

Meeting modified Japanese Orthopedic Association Score expectations was independent of sex, age, smoking status, or underlying pathology, while the fulfillment of pain and Neck Disability Index expectations was not dependent on baseline scores, age, sex, body mass index, or smoking status.

Pain Relief Expectations vs Reported Pain Outcomes

“We found that patient satisfaction correlated well to PROMs,” stated Dr. Meyer to OTW, “but patient expectations did not. Pain outcome scores (and meeting expectations) were correlated with satisfaction to a higher degree than functional outcome scores. Low Neck Disability Index expectations might predict dissatisfaction at 12 months after surgery. It was impressive to realize that pain was the most important variable influencing satisfaction not only in patients suffering from radiculopathy, but also in cervical spondylotic myelopathy patients.”

Going forward, researchers must tread carefully, with the authors writing, “To further investigate the impact of patient expectations on satisfaction and outcome, studies actively influencing patients’ expectations would be needed, which remains ethically delicate.”