Decisional Regret Among Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity: A Single Institutional Study : Spine

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Decisional Regret Among Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity: A Single Institutional Study

Adogwa, Owoicho MD, MPHa,b; Caruso, James P. BA, MDa,b; Eldridge, Cody M. BSa,b; Singh, Ravinderjit BSa,b; Chilakapati, Sai BSa,b; Deme, Palvasha BSa,b; Stutzman, Sonja PhDa; Aoun, Salah G. MDa,b; Naik, Aanand D. MDc,d; Bagley, Carlos A. MD, MBAa,b; Makris, Una MD, MSce

Author Information
SPINE 47(8):p E337-E346, April 15, 2022. | DOI: 10.1097/BRS.0000000000004287

Erratum

In the April 15, 2022 issue of Spine in the article by Adogwa et al, “Decisional Regret Among Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity: A Single Institutional Study”, the author Salah Aoun should be listed as Salah G. Aoun.

The article has been updated online.

Spine. 47(23):E627, December 1, 2022.

Adult spinal deformity (ASD) is a complex and debilitating pathology that presents with progressive pain, neurologic deficits, and functional impairment. Among noninstitutionalized older adults (age ≥65 yrs), ASD-related pain ranks in the top five of common causes of disability.1 An estimated 60% to 70% of older adults are afflicted with ASD,2 and as the baby boomer generation reaches retirement age,3 the number of older adults with symptomatic ASD will continue to rise.

While for some older adults, surgery is beneficial and results in functional improvement, in over 20% of older adults outcomes from surgery are less desirable.4,5 An estimated 50% to 75% of older adults experience postoperative complications (minor or major), such as wound infection, cardio-pulmonary complications, and delirium—all of which can contribute to delayed recovery after surgery, and in some cases death.6–8 Furthermore, polypharmacy, reduced treatment tolerance secondary to frailty, and fragmented social support systems, make older adults an especially vulnerable population.

The discussion of trade-offs when deciding between surgery and nonoperative strategies presents a considerable decision-making challenge for older adults, their families, and the health care team.9,10 Consequently, this complex treatment decision must be tailored to a patients’ personal values, risk tolerance, desired outcomes, and quality of life considerations.11–14 While studies have consistently demonstrated that the majority of ASD patients are happy with their treatment decision, regret over the selected treatment may be a more important and sensitive psychosocial outcome. Treatment decisional regret occurs when uncertainty about the best choice is unresolved or when an unfavorable outcome leads to the perception that another decision might have been prefer-able.15–17 At present, little is known about the frequency of and reasons for decisional regret following a treatment decision to undergo surgery for correction of ASD.

To address this unmet need, the authors present the first analysis of demographic, procedural, and clinical outcome variables that contribute to treatment decisional regret in older adults undergoing corrective surgery for ASD.

METHODS

Patient Selection

This is a retrospective, single site study of 155 consecutive older adult patients (≥65 years old) with a diagnosis of adult spinal deformity who underwent more than or equal to four level fusion to the sacrum with iliac fixation at a quaternary medical center from January 2016 to March 2019. Patient reported outcomes as well as operative details were retrieved from the spine center's prospective registry. Institutional Review Board approval was obtained prior to initiation of the data collection.

The primary reasons for surgery included progressive deformity, sagittal or coronal imbalance, progressive back pain, or neurogenic claudication unresponsive to nonoperative treatment. All patients included in the study met at least one or more of the following radiographic criteria (1) sagittal vertical axis (SVA) more than or equal to 50 mm; (2) lumbar lordosis less than 30°; (3) thoracic kyphosis more than or equal to 60°;(4) pelvic tilt more than or equal to 25°; or (5) pelvic incidence minus lumbar lordosis (PI-LL) mismatch of over 10°; (6) age more than or equal to 65 at the time of surgery; and (7) a minimum 12 months since the time of surgery. Bilateral sacral screw and bilateral pelvic fixation were placed in all patients. Pelvic fixation consisted of either iliac screws or S2 alar-iliac screws. Local bone (no iliac bone graft), fresh frozen allograft, and recombinant bone morphogenetic protein (rhBMP-2) were used on all patients. We excluded patients if their spinal deformity resulted from active infection, trauma, or tumors.

A manual chart review was performed for all patients who met the inclusion criteria. All patients were contacted by telephone to participate in the study, and those agreeing to participate were consented via telephone. Four attempts were made to contact each patient before asserting that the patient could not be contacted.

Primary Outcome

The primary outcome measure was decisional regret assessed using the Ottawa decision regret questionnaire. The Ottawa decision regret questionnaire18,19 is a validated 5-item Likert scale with high test and retest reliability, and validated for use in older adults.20,21 Respondents indicate the extent to which they agree or disagree with statements in the regret scale by indicating a number from 1 (strongly agree) to 5 (strongly disagree). Scores are converted to a 0 to 100 scale by subtracting 1 from each item then multiplying by 25 and the final score summed and averaged. A score of 0 reflects no regret; less than 40 low regret; 40 to 60 medium regret; and a score of more than 60 reflects high regret.

Preoperative and Intraoperative Variables

Demographic variables included patient age, sex, and body mass index (BMI). Based on manual review of the electronic medical record problem list, we included the following comorbidities—diabetes, hypertension, congestive heart failure (CHF), cerebrovascular accident (CVA), smoking, chronic obstructive pulmonary disease (COPD), anxiety, depression as well as American Society of Anesthesiologists (ASA) score. Intraoperative and postoperative variables included number of vertebral levels fused, estimated blood loss, duration of surgery, length of stay in the intensive care unit, length of hospital stay, number of days from surgery to ambulation, discharge disposition. Postoperative complications included implant failure, pseudarthrosis, wound dehiscence, wound infection, need for revision surgery—all confirmed by manual review of electronic medical records.

Patient Reported Outcomes (PROs)

Patient-reported outcomes instruments included the Oswestry disability index (ODI),22,23 Patient-reported Outcomes Measurement Information System (PROMIS-Pain), and numeric rating scales for back and leg pain.24,25 All questionnaires were self-administered and completed preoperatively, then at 3,6,9, and 12-months postoperatively. PROs were retrieved from the spine center's prospective registry. The ODI assesses back-specific function and contains 10 questions with six response categories. Higher scores denote increasing disability or higher pain levels. Each variable is rated on a 0- to 5-point scale and transformed into a percentage score. The range of possible values are from 0 to 100 (0–20 = minimal disability; 21–40 = moderate disability; 41–60 = severe disability; 61–80 = crippled; 81–100 = bedbound). PROMIS T-scores are standard scores with a mean of 5 and standard deviation of 1 in a refence population (usually the United States general population). Higher scores denote increasing disability or higher pain levels. T-scores range from 2 to 8 (0–5.5 = no disability; 5.5–6.0 = mild disability; 6–7 = moderate disability; ≥7 = severe disability).26,27 Numeric rating scales for back and leg pain range from 0 to 10, with 10 being the worst pain imaginable.24,25 These instruments have been widely used and accepted in the spine literature and have shown good construct validity.

Statistical Analysis

The prespecified primary outcome measure was the frequency of regret following surgery for correction of ASD. Normally distributed continuous variables were reported as means (SD) and nonnormally distributed variables as medians (interquartile ranges [IQR]). Categorical variables were presented as percentages and compared using the Chi squared or the Fisher exact test. Variables were also compared with the t test or the Mann–Whitney U test. We evaluated medium/high decisional regret compared with low regret. The decision to combined medium and high decisional regret categories was based on clinical experience. Adjusted ORs were estimated by multivariate logistic regression with inclusion of covariate terms for sex, depression, ASA score, invasiveness of surgery (number of vertebral levels fused), and presence of a postoperative complication. The independent variables included in the regression model were chosen based on clinical experience, and those likely to impact outcomes of surgery in spine patients. Hosmer-Lemeshow test, as well as Akaike's information criterion and Bayesian information criterion were used to evaluate model calibration. All tests were two-sided and were statistically significant if the P value was <0.05. Statistical analysis was performed using Stata, version 16 (StataCorp.2019. Stata Statistical Software, College Station, TX).

RESULTS

We identified 155 patients who met the inclusion criteria within the specified study period. A total of 91 patients (response rate 59%) consented to participate in the study, completed the questionnaire, and were included in the final analysis. Fifty five patients declined or could not be contacted and nine were deceased by the time of the study. When compared with patients who completed the interviews, patients who did not complete phone interviews had similar baseline comorbidities, invasiveness of surgery (i.e., number of vertebral levels fused), prevalence of postoperative complications, as well as 30- and 90-day hospital readmission rates, Table 1.

TABLE 1 - Participant Characteristics, Demographics, and Comorbidities
Characteristics Completed Decision Regret Survey (n = 91) Did not Complete Decision Regret Survey (n = 64) P-Value
Patient age, yr 70.82 ± 3.40 67.68 ± 1.56 0.02
Gender (% Male) 32.61 34.38 0.86
BMI, kg/m2 29.09 ± 6.94 29.85 ± 6.70 0.49
Marital status (%) 0.43
Divorced 7.00 9.00
Married 66.00 40.00
Single 9.00 8.00
Widowed 8.00 6.00
Race (%) 0.74
Asian 0.00 1.69
Black 5.61 1.69
White 93.26 96.61
Hispanic 1.12 0.00
Diabetes (%) 16.30 12.50 0.64
Depression (%) 28.26 31.25 0.72
Hypertension (%) 72.83 62.50 0.22
CHF (%) 6.52 7.81 0.76
CVA (%) 7.61 4.69 0.52
COPD (%) 13.04 7.81 0.43
Anxiety (%) 17.39 32.81 0.04
Osteoporosis (%) 21.74 29.69 0.39
Osteopenia (%) 64.13 53.12 0.39
Length of surgery, min 303.42 ± 105.25 334.70 ± 147.31 0.12
Estimated blood loss, mL 1656 ± 1255.28 1602.96 ± 1361.89 0.77
Mean number of vertebral levels (CI) 8.31 (7.77–8.86) 8.39 (7.55–9.22) 0.87
Type of osteotomy (%) 0.13
PCO 5.43 3.12
PSO 4.35 10.94
VCR 5.43 12.50
Upper instrumented vertebrae (%) 0.11
Upper thoracic 17.39 28.12
Lower thoracic 82.61 71.88
LOS (days, CI) 5.80 (5.46–6.14) 6.54 (5.49–7.60) 0.12
Postoperative complications (%) 31.52 34.38 0.73
30-day hospital readmission (%) 5.43 9.38 0.36
90-day hospital readmission (%) 9.78 12.50 0.61
Length of follow up (yrs, CI) 2.32 (2.12–2.52) 2.50 (2.20–2.70) 0.31
CHF indicates congestive heart failure; CVA, cerebrovascular accidents; COPD, chronic obstructive pulmonary disease; LOS, length of stay; PCO, posterior column osteotomy; PSO, pedicle subtraction osteotomy; VCR, vertebral column resection.

Participant Characteristics

Baseline characteristics of the study participants who completed the phone interviews and were included in the analysis (n = 91, 59%) are included in Table 2. The mean [SD] age was 70.82 ± 3.40 years, 32.61% of patients were men and the majority were White (93.26%). The mean [SD] BMI was 29.09 [6.94] kg/m2. 29.53% were current smokers, and 21.74% had osteoporosis.

TABLE 2 - Baseline Demographic Characteristics of Survey Responders With Medium/High and Low-Decisional Regret
Characteristics Medium/High Decisional Regret (n = 19) Low Decisional Regret (n = 72) P-Value
Patient age, yr 70.15 ± 4.87 70.95 ± 4.27 0.16
Gender (% male) 31.58 31.94 0.99
BMI, kg/m2 28.10 ± 5.84 28.71 ± 6.71 0.09
Current smokers (%) 26.32 30.56 0.21
Marital status (%) 0.55
Divorced 0.00 9.72
Married 89.47 66.67
Single 5.26 11.11
Widowed 5.26 9.72
Diabetes (%) 10.53 18.06 0.72
Depression (%) 47.37 23.61 0.05
Anxiety (%) 36.84 12.50 0.03
Hypertension (%) 63.16 75.00 0.38
CHF (%) 10.53 5.56 0.60
CVA (%) 15.79 5.56 0.15
COPD (%) 15.79 12.50 0.70
Osteoporosis (%) 21.05 22.22 0.51
Osteopenia (%) 57.89 66.67 0.51
CHF indicates congestive heart failure; CVA, cerebrovascular accidents; COPD, chronic obstructive pulmonary disease; PCO, posterior column osteotomy; PSO, pedicle subtraction osteotomy; VCR, vertebral column resection.

Among patients who underwent surgery for correction of ASD and who were surveyed, 20.65% reported medium/high decisional regret, and 79.35% low decisional regret. Comparing across regret groups, there were no statistically significant differences in the baseline demographics or clinical characteristics between the groups of patients’ expressing high versus low decisional regret, Table 2. However, the rates of depression and anxiety were significantly higher in the high decisional regret group, P = 0.05 and P = 0.03, respectively.

Decisional Regret

Figure 1, presents the results of the regret questionnaire. Overall, 80% of patients agreed or strongly agreed that having surgery was the right decision for them. A total of 77% said that they would make the same choice in the future. One out of every five patients (21%) responded that the decision to have surgery caused them harm, and similarly, one out of every five patients (21%) regretted the choice that they made.

F1
Figure 1:
Response to Ottawa decision regret survey among older adults who underwent surgery for adult spinal deformity.

Comparison of Intraoperative/Perioperative Variables

As outlined in Table 3, the proportion of primary and revision surgical procedures were similar across both groups (P = 0.47). There were no statistically significant differences between patient groups in the mean [SD] number of vertebral levels fused (P = 0.20), duration of surgery (P = 0.09), or rates of posterior column or 3 column osteotomies (P = 0.72). The proportion of patients with upper instrumented vertebrae terminating in the upper thoracic (T2, T3, T4) versus lower thoracic(T10, T11, T12) spine were statistically similar between high, and low-decisional regret groups. The length of in-hospital stay was 6.36 [1.83] days in the high decisional regret group, and 5.65 [1.56] days in the low decisional regret group. This difference was not statistically significant. Overall, the majority of patients (63.33%) were discharged to an inpatient rehabilitation facility, with a minority discharged directly home (28.89%) or to a nursing facility (7.78%). However, there was no statistically significant difference in the discharge dispositions (home/inpatient rehabilitation/ skilled nursing facility) between high, and low decisional regret groups, Table 4.

TABLE 3 - Comparison of Operative and Perioperative Variables Between Medium/High, and Low Decision Regret Groups
Characteristics Medium/High Decisional Regret (n = 19) Low Decisional Regret (n = 72) P-Value
Mean number of vertebral levels fused (SD) 9.00 ± 2.72 8.13 ± 2.61 0.20
Estimated blood loss, mL 1744.73 ± 1762.56 1635.21 ± 1106.43 0.73
Length of surgery, min 339.94 ± 165.60 293.84 ± 82.43 0.09
ASA grade [IQR] 3 [2–3] 3 [2–3] 0.75
Type of osteotomy (%) 0.72
PCO 10.53 4.17
PSO 0.00 5.56
VCR 0.00 6.94
Upper instrumented vertebrae (%) 0.31
Upper thoracic 26.32 15.28
Lower thoracic 73.68 84.72
LOS (days, CI) 6.36 ± 1.83 5.65 ± 1.56 0.09
Discharge disposition (%) 0.92
Skill nursing facility 5.26 8.57
Acute rehabilitation 68.42 61.43
Directly home 26.32 30.00
30-day hospital readmission (%) 10.53 4.17 0.27
90-day hospital readmission (%) 10.53 9.72 0.99
Length of follow up (yrs, SD) 2.31 ± 0.67 2.34 ± 1.02 0.89
CHF indicates congestive heart failure; CVA, cerebrovascular accidents; COPD, chronic obstructive pulmonary disease; LOS, length of stay; PCO, posterior column osteotomy; PSO, pedicle subtraction osteotomy; VCR, vertebral column resection.

TABLE 4 - Postoperative Complications Rate Across all Three Patient Cohorts
Characteristics Medium/High Decisional Regret (n = 19) Low Decisional Regret (n = 72) P-Value
Postoperative complication rate (%) 47.37 27.78 0.16
Implant failure (%) 21.05 12.50 0.30
Infection (%) 15.79 2.78 0.06
Wound dehiscence (%) 10.53 6.94 0.63
Junctional failure (%) 15.79 9.72 0.43
Pseudarthrosis (%) 5.26 0.00 0.20
Need for revision surgery (%) 26.32 12.50 0.15

Postoperative Variables

Overall, 31.52% of patients had a postoperative complication, with the most common complications being implant failure (14.13%) followed by junctional failures (10.87%), Table 4. Comparing across regret groups, there was no statistically significant difference in the rate ofpostoperative complications between the medium/high, and low deci-sional regret groups (P = 0.11), Table 4.

Patient Reported Outcomes

At baseline, the extent of pain and functional disability were not different between medium/high, and low decisional regret groups, Table 5. The mean [SD] ODI for the entire cohort was 41.85 [15.58] (high decisional regret: 40.50 [9.78] vs. low decisional regret: 42.17 [16.62], P = 0.78), Table 5. Similarly, there were no statistically significant differences between groups in baseline PROMIS scores (P = 0.88), VAS-BP (P = 0.59), and VAS-LP scores (P= 0.80). At 6 months after surgery, the extent of functional improvement was significantly greater in the low decisional regret group across all patient centered measures assessed. However, the observed difference at 6-months was attenuated over time. At 12-months after surgery, there was no statistically significant difference between both groups in the extent of functional improvement across all patient reported outcomes measures, Table 5, Figure 2.

TABLE 5 - Change From Baseline in Patient Reported Outcomes Measures and Results of Multivariable Regression Model
Characteristics Medium/High Decisional Regret (n = 19) Low Decisional Regret (n = 72) P-Value
Baseline
 ODI (SD) 40.50 ± 9.78 42.17 ± 16.62 0.78
 VAS-BP (SD) 6.00 ± 3.16 6.54 ± 2.56 0.59
 VAS-LP (SD) 5.50 ± 2.92 5.20 ± 3.11 0.80
 PROMIS (SD) 6.00 ± 1.76 6.11 ± 2.32 0.88
3-months
 ODI (SD) 49.00 ± 15.55 30.00 ± 16.21 0.13
 VAS-BP (SD) 5.50 ± 2.12 3.43 ± 2.50 0.27
 VAS-LP (SD) 1.50 ± 0.70 1.77 ± 1.90 0.84
 PROMIS (SD) 4.00 ± 0.00 3.66 ± 2.23 0.83
6-months
 ODI (SD) 46.57 ± 20.93 27.06 ± 16.50 0.01
 VAS-BP (SD) 5.71 ± 2.62 3.20 ± 1.98 0.01
 VAS-LP (SD) 4.42 ± 3.50 2.20 ± 2.22 0.03
 PROMIS (SD) 5.85 ± 2.34 3.32 ± 1.88 0.01
9-months
 ODI (SD) 26.40 ± 13.44 32.31 ± 15.39 0.45
 VAS-BP (SD) 4.33 ± 2.73 3.47 ± 2.73 0.50
 VAS-LP (SD) 3.66 ± 3.14 1.90 ± 2.58 0.17
 PROMIS (SD) 4.33 ± 2.65 4.15 ± 2.51 0.87
12-months
 ODI (SD) 36.40 ± 21.09 29.27 ± 16.23 0.25
 VAS-BP (SD) 5.54 ± 2.87 3.97 ± 2.53 0.08
 VAS-LP (SD) 3.45 ± 2.87 3.02 ± 2.99 0.67
 PROMIS (SD) 4.80 ± 2.29 4.02 ± 2.60 0.40
Multivariate Binary Logistic Regression Model
Variables Unadjusted OR [CI] Adjusted OR [CI] P-Value
Depression 4.08 [1.27–13.08] 3.97 [1.06–14.91] 0.04
Number of levels fused 1.12 [0.93–1.35] 1.06 [0.86–1.30] 0.57
Gender 1.01 [0.34–3.01] 0.71 [0.21–2.34] 0.56
ASA score 1.37 [0.46–4.04] 1.16 [0.35–3.87] 0.80
Postoperative complication 2.34 [0.82–6.60] 2.62 [0.85–8.04] 0.09
ODI indicates Oswestry disability index; VAS-LP, visual analog scale leg pain; VAS-LP, visual analog scale back pain. Statistically significant.

F2
Figure 2:
Change in health-related quality of life measures assessed over a period of 12 months after surgery.

Factors Associated With High Decisional Regret

Table 5, shows the multivariable-adjusted association between patient-level factors associated with high decisional regret. After adjusting for sex, ASA score, surgical invasiveness, and presence of postoperative complications, older adults with a history of depression had a 4.0-fold increased odds of high decision regret after surgery (P = 0.04) compared with those without depression.

DISCUSSION

In our study, most older adults that underwent surgery for correction of ASD agreed or strongly agreed that having surgery was the right decision for them and that they would make the same choice in the future. However, one-in-five older adults (21%) expressed decisional regret; and similarly, one-in-five (21%) responded that the decision to proceed with surgery caused them harm. Preoperative depression considerably influenced patient decisional regret, independent of surgical effectiveness; while the occurrence of postoperative complications or invasiveness of surgery did not. Understanding patient-level attributes associated with feelings of regret among older adults is important to improve and inform shared-decision making, drive goal-directed care, as well as optimize preoperative risk stratification.

Our findings that decisional regret is relatively common is consistent with other studies of surgical patients (range 2–40%).16,17,28,29 The preponderance of these studies were in oncology patients with comparatively fewer studies in non-oncology patients.17,30 Decisional regret rates tended to be higher in oncology patients compared with non-oncology patients.31,32 This observed difference is likely multifactorial and may be attributed to greater urgency to make a decision to move forward with treatment. While the prevalence of decisional regret in this study (21%) falls within the previously reported range, it is noticeably toward the upper end among non-oncologic studies,33–36 however likely an underestimate of the true prevalence rates of decisional regret following deformity correction in this patient population. Older adults with spinal pathologies have a tendency to overestimate the potential benefits of surgery, often believing that a decision to have surgery is aligned with their desired outcome goals and will cure their pain and disability, when this is not always the case. The overestimation of the benefits of surgery and discordance between treatments rendered and desired outcomes, may be attributed to inadequate informed consent, as well as surgeon lack of experience or discomfort in eliciting patient health priorities.

Depression was associated with high decisional regret, despite treatment effectiveness. Multiple studies have examined the role of preoperative depression on surgical outcomes after spinal surgery.37–42 These studies primarily focus on the relationship between depression and patient satisfaction (or health related quality of life measures), and not treatment decisional regret, which may be a more important and sensitive psychosocial outcome. Furthermore, only a few studies were limited to older adults. Hence, our focus on older adults, where late life pain impacts priorities and daily activities in different ways from younger populations, is unique. Despite differences in the primary outcomes of these studies, their findings of an inverse relationship between depression and outcomes is consistent with ours. Depression and chronic non-cancer pain syndromes are highly prevalent in older adults43 and the cooccurrence likely influences their perception of the surgical experience and improvement in ways that other comorbidities do not; consequently, contributing to decisional regret. This association is less prevalent in younger patients, highlighting the need for increased emphasis on treatment concordance with health priorities in this vulnerable older adult population.

In contrast to other published studies that found postoperative adverse events to be a driver of decision regret, we found no association between the presence of a postoperative complication and treatment decisional regret.17,44 One explanation for the observed difference could be the time period during which the studies were conducted. Studies conducted earlier than the 2000 s were more likely to find a positive association compared with studies conducted after 2000 s. This observation could reflect differential emphasis on the informed consent process over time. Another explanation could be patient age at the time of surgery or preoperative expectations of outcomes. Our study was limited to patients 65 years and older, suggesting that postoperative adverse events may impact older adult patients’ perception of a successful outcomes differently than younger patients.

The results and implications of the current analyses should be interpreted within the context of its limitations. While there was no statistically significant association between postoperative complications and decisional regret, early postoperative complications clearly affected patients's long-term perception of surgical success. Almost 50% of patients in the high decisional regret group experienced a postoperative complication compared with 27% in the low decisional regret group. This study may not have been sufficiently powered to detect a difference. The retrospective study design risks selection bias andtreatmentbias, althoughweattemptedtominimizethese effects by limiting our population to a single institution with standardized pre- and postoperative care pathways. Our strict inclusion criteria and expansive data collection were designed to limit error from a heterogeneous population or an incomplete database. Since patients were asked about decisions that occurred 2 years earlier, responses were subject to recall bias.

While the response rate in our study was low (59%), patients who declined to participate had similar demographic, radiographic, and surgical profiles compared with the patients who participated in the study. Additionally, there were no significant difference in the PROMs between patients who agreed to participate and those who did not, suggesting that the missing data was missing completely at random (MCAR), and less likely to bias the results. The presence of depression or anxiety were obtained from the patients problem list in the electronic medical record, and not via a validated research questionnaire. In addition, whether the affective disorders were primary or secondary to chronic pain on disability is not known. Despite these limitations, this study identifies patient-level factors that influence treatment decisional regret among older adults undergoing deformity correction. It is our hope that our findings inform future prospective, multicenter analyses evaluating how decisional regret changes at different follow-up intervals and whether long-term decisional regret is associated with impaired clinical outcomes. Ultimately, we hope that the data we present will facilitate the development of preoperative screening tools to identify patients who are at risk for decisional regret and may benefit from further preoperative counseling, risk assessment, and medical optimization. Developing communication tools and strategies to elicit patient priorities prior to surgery is another area ripe for investigation.

CONCLUSION, CLINICAL IMPLICATIONS AND FUTURE DIRECTIONS

Our findings are particularly relevant given the rapidly growing older adult population with spinal deformities facing challenging decisions between selecting surgery or conservative care that presents a potential tradeoff between symptom relief and undesirable adverse events. Deformity correction surgery in this vulnerable patient population, without a clarification of patient values and assessing whether treatment decisions are congruent with these values, are missed opportunities for surgeons and ultimately, may result in unacceptable outcomes. Understanding a taxonomy of treatment outcome goals from the older adult perspective, and an understanding of what patients are willing and unwilling to do to achieve what matters most to them will provide novel opportunities to improve care delivery, including patient engagement and shared decision making. Finally, regret has almost exclusively been studied from a patients’ perspective. Examining surgeons’ comfort and experience with eliciting patient health priorities, and their perception of its usefulness in the treatment of older adults considering spine surgery, may hopefully lead to improved shared decision making and enhanced the patient-surgeon relationship.

Key Points

  • The majority of older adults were appropriately counseled and satisfied with their decision to have corrective surgery for spinal deformity.
  • One-in-five older adults regret their decision to undergo surgery.
  • Preoperative depression was associated with medium/high decisional regret on multivariate analysis.

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Keywords:

adult spinal deformity; decisional regret; geriatric; outcomes patient regret; spine surgery

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