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The Spine Blog

Friday, August 31, 2012

The Importance of Shared Decision Making for Disk Herniation Patients

While most spine surgery literature has focused on comparing outcomes of different treatments and determining predictors of outcomes, the majority clinicians would agree that the strongest predictor of patient satisfaction is how well a patient’s treatment preferences matched the treatment actually received. Experienced providers know that patients who are talked into surgery—even if they benefit from it—and patients who are dissuaded from surgery—even if it is unlikely to help them—are rarely happy with the end result, even if it is the best result they could get from a physiological standpoint.  Until now, there has been little effort to quantitatively assess the quality of decision making in disk herniation patients. While multiple decision aids have been produced for this condition, there has been little written about their effect on decision-making quality and patient satisfaction with their decision making. In the August 15 issue, Dr. Sepucha and her colleagues from Boston and Dartmouth evaluated the effect of a decision aid on disk herniation patients’ knowledge and the effect of the concordance of their beliefs and treatment decision on their decisional satisfaction. Not surprisingly, they found that watching a decision aid significantly improved patients’ knowledge. Also important, but again not surprising, was that patients who made a treatment decision in line with their beliefs were significantly less likely to experience decisional regret (13% vs. 39%). This paper makes it clear to clinicians that employing a high-quality decision aid can improve patient knowledge and likely help them clarify their goals and desires and make a treatment decision in line with these values.


Reading this paper leaves the reader understanding how little we know about the incredibly important process of treatment decision making, especially for cases of preference-sensitive care (like disk herniation) where there is no “medically correct” answer. The majority of spine clinicians now understand that correct patient selection is likely far more important than the technical details of how one actually does an epidural steroid injection or a discectomy. Even our understanding of patient selection—which used to be based on the flawed idea of selectively operating on patients likely to have the best surgical outcomes—has evolved to selecting surgical patients who will most likely have the most improvement with surgery relative to their likely nonoperative outcomes. Unfortunately, our understanding of the process through which patients and their providers come to a treatment decision remains limited. This paper makes it clear that in order to avoid “decisional regret”, a most undesirable outcome for patient and clinician alike, surgeons must both educate patients about their condition and treatment options and also spend the time to determine the values that frame their decision. One of the most interesting findings of this paper is that while 22% of patients made a treatment decision discordant with their values, 17% chose surgery when their values were more consistent with nonoperative treatment while only 5% chose nonoperative treatment when their values were more consistent with surgery. This suggests an imbalance in either the information or advice being given to patients in that more of them were convinced to have a surgery they probably did not want compared to the number who ended up choosing nonoperative treatment when their values were more consistent with surgery. Surgeons should take these data to heart and remind themselves that no one is going to be happy if they have to “sell” a patient an operation. Such practices are better left to car salesmen.


Please read Dr. Sepucha’s article and accompanying commentary. Does this article affect how you view the role of shared decision making for spine conditions? Let us know by posting a comment on The Spine Blog.


Adam Pearson, MD, MS

Associate Web Editor