Saturday, December 8, 2018
A crystal ball for spine patients?
If spine patients and their surgeons could see the future, surgical decision-making would be very easy. The patient would know how they would do with surgical or non-operative care and then choose the option that leads to their preferred result. Unfortunately, the science of predicting spine patient outcomes based on individual characteristics is in its infancy. In an effort to individualize outcome predictions for patients with disk herniation, spinal stenosis, and degenerative spondylolisthesis, Haley Moulton and colleagues from Dartmouth-Hitchcock, Washington University, and OrthoCarolina worked with Consumer Reports using data from the Spine Patient Outcomes Research Trial (SPORT) to develop outcomes prediction models for surgical and non-operative treatment for each diagnosis. The outcomes included were the SF-36 physical function score, sciatica or stenosis bothersomeness index, sleep quality, and sex life. Consumer Reports worked with investigators to create a user-friendly website for patients that provided information about their condition and an individualized prediction of surgical and non-operative outcomes out to 8 years based on their characteristics. Two groups of respondents were queried: over 1,200 Consumer Reports subscribers known to have low back pain and 68 patients identified from spine center clinics. The Consumer Reports patients tended to be older and included a higher proportion of men with longer term, less severe symptoms as compared to those recruited from clinic. The Consumer Reports respondents were also not screened by a spine clinic provider, so they determined their own diagnostic category. The study participants were randomly assigned to take a knowledge quiz before or after using the website, and the group who took the quiz after using the website scored higher. Decisional conflict tended to be lower after using the website, though this was more pronounced for the Consumer Reports respondents. Overall, the participants found the calculator at least moderately useful, and the majority were very or completely satisfied with its ease of use.
To many spine providers, having an accurate way to predict surgical and non-operative outcomes for individual patients is the holy grail of surgical decision-making. It would allow for the selection of surgical patients who would have a high chance of surgical success and the avoidance of surgery in patients who would do just as well with non-operative treatment or be at high risk for a bad complication. A perfectly accurate prediction model will never exist, but an outcomes calculator like the one described here should help patients and surgeons make a more informed decision. This paper would have been stronger if more patients who were actual surgical candidates were enrolled. Only about 20% of patients identified in clinic and provided with a link to the website actually used it, suggesting that most patients were not particularly interested in using the program. It is possible that handing them a card with a web address they needed to type into their computer or phone was not the best way to recruit them into the study. It is harder to interpret the data from the Consumer Reports respondents as they self-identified as having one of the three conditions under study, and many of them were probably not surgical candidates (their patient reported outcome scores indicated much less severe symptoms compared to the clinic patients). It seems likely that prediction models will appeal to at least a substantial minority of relatively sophisticated patients who have an interest in this type of data. Other patients may prefer a simple treatment recommendation from their provider. In an ideal world, patient outcomes would be recorded in a registry, and the model's accuracy could be improved as more patients are followed. Individualized outcomes prediction represents a major addition to shared decision, and hopefully this information will help patients and surgeons come to the right treatment decision.
Please read Ms. Moulton's article on this topic. Do you think such a calculator would be helpful to you and your patients? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Wed Editor