Lisa Charbonneau, DO, MS Medical Director, New England Rehabilitation Hospital of Portland November 2014

 In this session, we will explore current state of knowledge on patient preferences and views on low back pain.

 The utility of patient satisfaction questionnaires – WHY? ▪ Identify ways to improve your practice ▪ Improve care delivery ▪ Results in more satisfied, happier patients ▪ Show staff that you are interested in quality ▪ Marketplace now demands data on patient satisfaction ▪ Provides quality data ▪ Enables practice comparisons standardized assessments on a broad scale

 We have entered the era of pay for performance measures  Patient satisfaction scores will figure into the equation for reimbursement for hospitals and physicians

▪ What do patients want? ▪ Clear diagnosis ▪ Information and instructions ▪ Pain relief ▪ A physical exam (touch the patient!)

▪ More diagnostic tests ▪ Other therapeutic modalities ▪ Referral to specialists ▪ Certification of disability ▪ Expert confirmation that “their pain is real”

▪ Understanding ▪ Listening ▪ Respect ▪ Inclusion in decision making

 Reviewing the spectrum of potential outcomes from increased function, elimination of pain to treatment of chronic low back pain ▪ Patient expectations are more influenced by family, friends and prior experiences ▪ Most patients with LBP expect an X-ray to identify “the cause of pain.” ▪ Prior relationship with their physician correlates to the degree of patient satisfaction

 Opioids +/- Cognitive Behavioral Therapy (CBT) had no effect on improving perceptions of pain, fatigue, level of distress in patients with chronic LBP (J. of Pain Research Jan 2012)

 Younger patients have higher expectations before surgery with regard to symptom relief, mobility and reducing the impact the condition has on current and future life.  Patients with more significant disability have higher expectations prior to (cervical) spine surgery.  Do we ask the right questions?

 Do we understand the scores?  Who is completing the questionnaire?  Are happy patients more or less likely to complete the questionnaire?  Should we “teach for the test?”  Do we spend enough time listening to our patients?

 One large center study of 422 patients found that extent of improvement in quality of life and disability did not correlate with patient satisfaction scores.  Study concluded that patient satisfaction is NOT a valid measure of overall quality or effectiveness of surgical spine care and should not be used as a proxy for overall quality, safety, or effectiveness of care. (Spine J, 2013 Sep;13(9): )

 How do we involve the public in the creation of CPG’s? ▪ Spine (2004) “Practice guidelines should pay more attention to the best way of discussing causes and diagnosis with patients and should involve them in decision making.”  Have we included patients in the creations of CPGs in the last decade?

▪ CPGs reviewed by AAPMR CPG committee in the area of back pain and Agree II score: ▪ NASS (Spinal Stenosis)1 ▪ NASS (Spondylolisthesis)1 ▪ AAOS (Sympt CF)3 ▪ APTA (CPG linked to ICF)1  The answer is NO!!!

 We know what patients want.  We have an idea of patient expectations.  Patient satisfaction scores do not correlate with quality of care.  We have not done a good job of including patients (lay public) in the creation of CPGs.  We are not “satisfying” patients because we are not creating realistic expectations and are not asking the right questions.

 Hoffman et al. Patients expectations of acute low back pain management. J Fam Prac 2013;14(7).  Sanderson, Kristen, et al. Investigating patient expectations and treatment outcome in a chronic low back pain population.J of Pain Research Jan 2012  Verbeck J, et al. Patient expectations of treatment for back pain; a systematic review of qualitative and quantitative studeis. Spine 2004 Oct 15;29(20)  AAPMR website CPGs endorsed by the Academy

 Godil SS et al, Determining the quality and effectiveness of surgical spine care:patient satisfaction is not a valid proxy.Spine J, 2013 Sep; 13(9):  Mancuso, CA et al, Patients’ expectations of cervical spine surgery, Spine. 2014;39(14):  Bowling A, et al, The measurement of patients’ expectations for health care: a review and psychometric testing of a measure of patients’ expectations. Health Technol Assess, 2012 Jul:16(30):i-xii