Do Patient Preferences Influence Surgeon Recommendations for Treatment?
Lisanne Johanna Henrica Smits, MD2; Suzanne Caroline Wilkens, MD2; David Ring, MD, PhD3; Thierry Guitton, MD PhD4; Neal C. Chen, MD2
1Massachusetts General Hospital, Boston, MA; 2Massachusetts General Hospital/Harvard Medical School, Boston, MA; 3Dell Medical School, Austin, TX; 4University Medical Center Gronigen, Groningen, Netherlands
Introduction: When the best treatment option is uncertain, a patient's preference based on personal values should be the source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation in treatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patient preferences. We aimed to determine if specific patient preferences influence surgeon treatment recommendations and if there are surgeon related factors associated with treatment recommendations
Materials & Methods: One-hundred-eighty-four surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operative treatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment. To test the influence of 6 specific patient preferences the preference was randomly assigned to each scenario in an affirmative or negative manner. Surgeon characteristics were collected for each participant.
Results: Of the 6 preferences studied, 4 influenced surgeon recommendations. Surgeons were more likely to recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR, 0.82; 95% CI, 0.71 - 0.94; p=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 - 0.95; p=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 - 1.3; p=0.046), and when patients only preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option (adjusted OR, 0.78; 95% CI, 0.68 - 0.89; p<0.001). Furthermore, experienced surgeons (adjusted OR, 1.44; 95% CI, 1.1 - 1.9; p=0.015), surgeons supervising trainees (adjusted OR, 1.37; 95% CI, 1.0 - 1.8; p=0.038), and surgeons practicing in Australia/Asia (adjusted OR, 1.77; 95% CI, 1.3 - 2.5; p=0.001) or Europe (adjusted OR, 1.27; 95% CI, 1.0 - 1.6; p=0.036) recommended operative treatment more often. Whereas orthopeadic trauma surgeons recommended operative treatment less often (adjusted OR, 0.78; 95% CI, 0.62 - 0.98; p=0.035).
Conclusions: Patient preferences were found to have a measurable influence on surgeon treatment recommendations--though not as much as we expected--and surgeons on average interpreted surgery as more aesthetic which seems to presume that a scar and potential implant prominence are less bothersome to people than a deformity. This emphasizes the importance of strategies to help patients reflect on their values and ensure their preferences are consistent with those values (e.g. use of decision-aids).
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