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Involving Patients in Clinical Decisions: Impact of an Interactive Video Program on Use of Back Surgery

Deyo, Richard A. MD, MPH*†§; Cherkin, Daniel C. PhD†‡¶; Weinstein, James DO, MS#; Howe, John MD; Ciol, Marcia PhD; Mulley, Albert G. Jr, MD, MPP**

Original Articles

Background. Back surgery rates are rapidly rising in the United States. This surgery is usually elective, so patient preferences are important in the treatment decision.

Objectives. The objective of this study was to determine the impact on outcomes and surgical choices of an interactive, diagnosis-specific videodisk program for informing patients about treatment choices.

Research Design. This was a randomized, controlled trial at 2 sites comparing the interactive video plus a booklet with the booklet alone.

Subjects. Elective surgery candidates (n = 393) included 171 patients with herniated disks, 110 with spinal stenosis, and 112 with other diagnoses.

Measures. Mailed questionnaires were used to assess outcomes and satisfaction; surgery rates were determined by questionnaires and automated records.

Results. Symptom and functional outcomes at 3 months and 1 year were similar between study groups. The overall surgery rate was 22% lower in the videodisk group (26% versus 33%, P = 0.08). Among patients with herniated disks, those in the video group underwent significantly less surgery (32% versus 47%, P = 0.05 by Kaplan-Meier test). Among patients with spinal stenosis, surgery rates in the video group were higher (39% for the video group, 29% for the booklet group;P = 0.4). There was little effect on patient satisfaction, but patients in the video group felt better informed.

Conclusions. The program appears to facilitate decision making and may help to ensure informed consent. For patients with herniated disks, it reduced the surgery rate without diminishing patient outcomes. Its impact on costs of care depends on the proportion of patients with various diagnoses and on local surgery rates.

*From the Department of Medicine, †Department of Health Services, ‡Department of Family Medicine, and §Center for Cost and Outcomes Research, University of Washington, Seattle, Washington. ¶From the Center for Health Studies and ∥Section of Neurological Surgery and Neurology, Group Health Cooperative, Seattle, Washington. #From the University of Iowa, Department of Orthopaedic Surgery, Iowa City, Iowa, and the Dartmouth-Hitchcock Medical Center and Dartmouth Medical School, Hanover, New Hampshire. **From the General Medicine Division, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts.

Presented in part at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Kona, Hawaii, June 21, 1999.

Supported by grant No. HS 08079 from the Agency for Health Care Policy and Research and by the Foundation for Informed Medical Decision-Making.

Received November 29, 1999;

initial review completed February 9, 2000; accepted May 18, 2000.

Address requests for reprints and other correspondence to: Richard A. Deyo, MD, MPH, Center for Cost and Outcomes Research, University of Washington, 146 N Canal St, Suite 300, Seattle, Washington 98103-8652. E-Mail:

© 2000 Lippincott Williams & Wilkins, Inc.