Growth in the Use of Shared-Decisionmaking Tools
According to experts, many patients may not understand the benefits and risks of surgery for lumbar spinal stenosis before undergoing the procedure. In particular, it is unclear whether patients are fully aware of the possibility that surgery may not improve their symptoms (which occurs in approximately 25 percent of patients) or that they may need a repeat procedure in the future. In many cases, physicians may believe that they have effectively communicated this information, but discussants mentioned to us that some physicians are just not good at enabling informed consent. The majority of experts we spoke with felt that use of these procedures was driven more by physician preferences than by patient preferences. Many believe that spine doctors tend to advocate for surgical treatment of spinal stenosis and that more-informed patient decisionmaking could help to better address patients’ preferences (Deyo, Mirza, et al., 2010).
While the use of decision aids appears to be a growing trend, many experts believe that they are not used frequently enough in spinal surgery. Some suggested that evidence from SPORT has been directly incorporated into patient decision aids for spinal stenosis surgery, including those developed by the Foundation for Informed Medical Decision Making, but their existence does not guarantee that decision aids will be used. One expert mentioned that decision-quality measures might help promote the use of decision aids and that such measures may soon be ready for use. Others argue that the effectiveness of decision aids is unclear. According to one discussant, surgeons thought the decision aid developed by Dartmouth for prostate surgery was too “anti-surgery,” while internists generally thought it was too “pro-surgery.”
Emergence of Radiology-Benefits Managers
Orthopedic surgeons indicated that diagnostic imaging is excessive, and experts stated that RBMs are being used more commonly by health plans to increase the appropriateness of diagnostic imaging procedures. RBMs may use administrative controls such as prior authorization or utilization review to limit the use of such procedures. Because spine magnetic resonance imaging (MRI) is commonly used to diagnose spinal stenosis and is potentially a key factor in the decision to refer patients for further evaluation, RBMs may ultimately play a significant role in influencing which patients undergo surgery. However, most of the experts with whom we spoke had limited knowledge about the impact of RBMs to date.