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In the Eye of the Beholder: Preferences of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery

Bederman, S Samuel, MD, PhD, FRCSC*†; Mahomed, Nizar N., MD, ScD, FRCSC; Kreder, Hans J., MD, MPH, FRCSC; McIsaac, Warren J., MD, MSc, CCFP, FCFP; Coyte, Peter C., PhD§; Wright, James G., MD, MPH, FRCSC

doi: 10.1097/BRS.0b013e3181b77f2d
Health Services Research

Study Design. Survey to all orthopedic and neurosurgeons, a random sample of family physicians (FPs) and patients in Ontario, Canada.

Objective. To identify the dominant clinical factors influencing patient and physician preferences for lumbar spinal surgery.

Summary of Background Data. Surgery on the degenerative lumbar spine offers significant benefit for patients with moderate-severe symptoms failing nonoperative treatment. Referring FPs have little appreciation of factors that identify the ideal surgical candidate. Differences in preferences may lead to wide variation in referrals and impedes the shared decision-making process.

Methods. We used conjoint analysis, a rigorous method for eliciting preferences, to determine the importance that respondents place on decisions for lumbar spinal surgery. We identified 6 clinical factors (walking tolerance, pain duration, severity, neurologic symptoms, typical onset, and dominant location of pain) and presented hypothetical vignettes to participants who rated their preference for surgery. Data were analyzed using random-effects ordered probit regression models and the importance of each clinical factor relative to the others was determined.

Results. We obtained responses from 131 surgeons, 202 FPs, and 164 patients. We found that FPs had the highest overall preferences for surgery and surgeons had the lowest. Surgeons placed the highest importance on the location of pain. FPs considered neurologic symptoms, walking tolerance, and severity to be of similar importance. Pain severity, walking tolerance, and duration of pain were the most important factors for patients in deciding for surgery. Orthopedic (over neurosurgical) surgeons had a lower preference for surgery (P < 0.05). Older patients (P < 0.03) and previous surgical consultation (P < 0.03) had greater patient preferences for surgery.

Conclusion. Different preferences for surgery exist between surgeons, FPs, and patients. FPs may reduce over- and under-referrals by appreciating surgeons' importance on location of pain (leg vs. back). Surgeons and FPs may improve the shared decision-making process by understanding that patients place high importance on quality of life symptoms.

A poor understanding of optimal surgical candidacy results in wide variation in referral rates for lumbar surgery. We found that surgeons placed the highest importance on dominant location of pain in deciding for surgery. Variation in referrals can be reduced by appreciating the importance of dominant pain location.

From the *Department of Orthopaedic Surgery, University of California, San Francisco, CA; †Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto ON; ‡Department of Family and Community Medicine, University of Toronto, Toronto, ON; and §Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Acknowledgment date: March 11, 2009. Revision date: May 1, 2009. Acceptance date: May 4, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Supported by a grant from the Ontario Neurotrauma Foundation and Ontario Ministry of Health and Long-Term Care, and salary support provided by a Clinical Research Training Fellowship from the Orthopaedic Research and Education Foundation and American Academy of Orthopaedic Surgeons (to S.S.B.).

Research Ethics Board approval was obtained from the University of Toronto and the Hospital for Sick Children, Toronto, Canada.

Address correspondence and reprint requests to S. Samuel Bederman, MD, PhD, FRCSC, Department of Orthopaedic Surgery, UCSF, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143; E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.