Decisional Regret: Investigating the Patient Experience with Shared Decision Making as a Public Health Concern




Deme, Palvasha Reddy

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BACKGROUND: Among older adults (> 65 years old), adult spinal deformity (ASD) is a leading cause of disability, with a population prevalence of 60%-70%. Surgical referral for deformity correction is common despite the high rates of postoperative complications. Because surgery involves trade-offs between clear benefits and risks, the patient's perspective is essential in deciding whether or not to undergo surgery. LOCAL PROBLEM: The UT Southwestern Spine Center takes a multidisciplinary approach to the care of older patients through the implementation of the POSH (Perioperative Optimization of Senior Health) Program. This study will determine the prevalence of decisional regret in patients who have undergone spine surgery for symptomatic degenerative scoliosis and identify the root causes that may contribute to high decisional regret in these patients. METHODS: Older adults with a diagnosis of ASD who underwent spinal surgery at a quaternary medical center from January 2016 to March 2019, were enrolled in this study. Patients were categorized into medium/high or low-decisional regret cohorts based on their responses to the Ottawa decision regret questionnaire. Decisional regret assessments were completed 24 months after surgery. Using purposeful sampling we identified older adult patients who underwent deformity correction surgery between the aforementioned time period. We conducted semi-structured, in-depth interviews with six patients (average age 73 years old, 83% women, all white) and five spine surgeons (years in practice 3 - 11). Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS: Four themes emerged from interviews with patients: (1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; (2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; (3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and (4) patients felt that pain management was the most difficult part of recovery from surgery which wasn't discussed comprehensively by their surgeon/care team prior to surgery. Four themes emerged from interviews with surgeons: (1) although spine surgeons intuitively understood the concept of shared decision making, they varied substantially in their interpretations; (2) spine surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; (3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and (4) spine surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION: While the majority of older adults were appropriately counselled and satisfied with their decision, one-in-five older adults regret their decision to undergo surgery. Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery for older adults with symptomatic spinal deformity. These findings highlight the need for improved understanding of both sides of shared decision making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness.

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The content of this work is based on the previously published articles that are cited below. The author has permission from the publisher to use the works listed below within the thesis.

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Adogwa, O., Caruso, J. P., Eldridge, C. M., Singh, R., Chilakapati, S., Deme, P., Stutzman, S., Aoun, S. G., Naik, A. D., Bagley, C. A., & Makris, U. (2022). Decisional regret among older adults undergoing corrective surgery for adult spinal deformity: A single institutional study. Spine (Phila Pa 1976), 47(8), E337-E346.
Deme, P., Perera, A., Chilakapati, S., Stutzman, S., Singh, R., Eldridge, C. M., Caruso, J., Vira, S., Aoun, S. G., Makris, U. E., Bagley, C. A., & Adogwa, O. (2022). Patient and spine surgeon perceptions on shared decision-making in the treatment of older adults undergoing corrective surgery for adult spinal deformity. Spine (Phila Pa 1976), 47(10), 730-736.