TY - JOUR
T1 - Facilitating surgical decisions for patients who are uncertain
T2 - A pilot surgical option process within an interdisciplinary functional restoration program
AU - Brede, Emily
AU - Mayer, Tom G.
AU - Worzer, Whitney E.
AU - Shea, Maile
AU - Garcia, Cristina
AU - Gatchel, Robert J.
N1 - Funding Information:
The writing of this article was supported in part by Grant 1K05 MH 71892 from the National Institutes of Health. This Senior Scientist Award to Dr Gatchel focuses on evidence-based assessment and treatment approaches to musculoskeletal pain, as well as the monitoring of valid outcomes.
PY - 2014/8/1
Y1 - 2014/8/1
N2 - Background context For chronic pain patients, recovery may be slowed by indecisiveness over optional surgery. These patients may be delayed from participating in interdisciplinary functional restoration (FR), pending resolution of the surgical decision. Uncertainty about surgery or rehabilitation leads to delayed recovery. A surgical option process (SOP) was developed to permit patients with chronic disabling occupational musculoskeletal disorders to enter FR, make a final determination halfway through treatment, and return to complete rehabilitation after surgery, if surgery was elected. Purpose This study assessed the frequency with which an FR program can resolve an uncertain surgical option. It also assessed program completion rate and 1-year post-program outcomes for subgroups that decline surgery, request and receive surgery, or request surgery but are denied by surgeon or insurance carrier. Study design Retrospective study of a consecutive cohort. Patient sample A cohort of 44 consecutively treated chronic disabling occupational musculoskeletal disorder patients were admitted to an FR program and identified as candidates for a surgical procedure but were either ambivalent about undergoing surgery, had a difference of opinion by two or more surgeons, or were denied a surgical request by an insurance carrier. Patients attended half (10 full day visits) of an FR program before making their own final determination to pursue a request or decline surgery. Outcome measures Patients were assessed on surgical requests and whether surgery was ultimately performed, program completion status after the surgical determination, demographic variables, and 1-year outcomes on work status, additional surgery, and other health utilization measures. Methods Patients became part of the SOP on program entry and were included in the study if they participated in a surgical-decision interview halfway through the program. Those who elected to decline surgery (DS) completed the program without delay, but those requesting surgery were placed on hold from the program while consultation and preauthorization steps took place. Those requesting surgery, but denied (RSD), and those undergoing surgery (US) were given the opportunity to complete FR following postoperative physical therapy or resolution of the surgical re-evaluation process. Results There were 32 DS patients (73%), indicating that a large majority of patients declined the surgery that was still being considered when offered participation in the SOP. Of the 12 patients wanting a surgery, there were four US patients who received surgery previously denied (9% of cohort), and eight RSD patients (18% of cohort). Patients from the DS group completed the FR program at an 88% rate, as did 75% of US patients. However, despite an opportunity to re-enter and complete rehab, only 50% of RSD patients completed the FR option. Overall, patients who persistently sought surgery, contrary to the recommendations of a surgeon, had poorer outcomes. These 1-year post-FR outcomes included lower return-to-work and work retention rates, with higher rates of treatment seeking from new providers (resulting in higher rates of post-discharge surgery) and higher rates of recurrent injury claims after work return. Conclusions A SOP tied to participation in an interdisciplinary FR program resolves uncertainty regarding surgical options in a high proportion of cases, resulting in a large majority declining surgery and completing the FR program. Timely surgery is also promoted decisively when needed. Findings suggest that patients who persistently seek surgery, contrary to the recommendations of a surgeon, frequently fail to complete FR and have poorer outcomes overall.
AB - Background context For chronic pain patients, recovery may be slowed by indecisiveness over optional surgery. These patients may be delayed from participating in interdisciplinary functional restoration (FR), pending resolution of the surgical decision. Uncertainty about surgery or rehabilitation leads to delayed recovery. A surgical option process (SOP) was developed to permit patients with chronic disabling occupational musculoskeletal disorders to enter FR, make a final determination halfway through treatment, and return to complete rehabilitation after surgery, if surgery was elected. Purpose This study assessed the frequency with which an FR program can resolve an uncertain surgical option. It also assessed program completion rate and 1-year post-program outcomes for subgroups that decline surgery, request and receive surgery, or request surgery but are denied by surgeon or insurance carrier. Study design Retrospective study of a consecutive cohort. Patient sample A cohort of 44 consecutively treated chronic disabling occupational musculoskeletal disorder patients were admitted to an FR program and identified as candidates for a surgical procedure but were either ambivalent about undergoing surgery, had a difference of opinion by two or more surgeons, or were denied a surgical request by an insurance carrier. Patients attended half (10 full day visits) of an FR program before making their own final determination to pursue a request or decline surgery. Outcome measures Patients were assessed on surgical requests and whether surgery was ultimately performed, program completion status after the surgical determination, demographic variables, and 1-year outcomes on work status, additional surgery, and other health utilization measures. Methods Patients became part of the SOP on program entry and were included in the study if they participated in a surgical-decision interview halfway through the program. Those who elected to decline surgery (DS) completed the program without delay, but those requesting surgery were placed on hold from the program while consultation and preauthorization steps took place. Those requesting surgery, but denied (RSD), and those undergoing surgery (US) were given the opportunity to complete FR following postoperative physical therapy or resolution of the surgical re-evaluation process. Results There were 32 DS patients (73%), indicating that a large majority of patients declined the surgery that was still being considered when offered participation in the SOP. Of the 12 patients wanting a surgery, there were four US patients who received surgery previously denied (9% of cohort), and eight RSD patients (18% of cohort). Patients from the DS group completed the FR program at an 88% rate, as did 75% of US patients. However, despite an opportunity to re-enter and complete rehab, only 50% of RSD patients completed the FR option. Overall, patients who persistently sought surgery, contrary to the recommendations of a surgeon, had poorer outcomes. These 1-year post-FR outcomes included lower return-to-work and work retention rates, with higher rates of treatment seeking from new providers (resulting in higher rates of post-discharge surgery) and higher rates of recurrent injury claims after work return. Conclusions A SOP tied to participation in an interdisciplinary FR program resolves uncertainty regarding surgical options in a high proportion of cases, resulting in a large majority declining surgery and completing the FR program. Timely surgery is also promoted decisively when needed. Findings suggest that patients who persistently seek surgery, contrary to the recommendations of a surgeon, frequently fail to complete FR and have poorer outcomes overall.
KW - Chronic disabling occupational musculoskeletal disorders
KW - Functional restoration
KW - Interdisciplinary
KW - Patient decision
KW - Return to work
KW - Socioeconomic outcomes
KW - Spinal fusion
KW - Surgical option process
UR - http://www.scopus.com/inward/record.url?scp=84905459730&partnerID=8YFLogxK
U2 - 10.1016/j.spinee.2013.06.108
DO - 10.1016/j.spinee.2013.06.108
M3 - Article
C2 - 24231775
AN - SCOPUS:84905459730
SN - 1529-9430
VL - 14
SP - 1686
EP - 1693
JO - Spine Journal
JF - Spine Journal
IS - 8
ER -