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 Table of Contents  
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 51-55

Frequent users of health-care services have worse outcomes of spinal surgery: Results from a web-based survey

1 Department of Neurosurgery, Specialist Medical Center, Polanica-Zdroj, Poland
2 Department of Neurosurgery, Regional Medical Center, Opole, Poland
3 Department of Neurosurgery, Regional Neurosurgery and Neurotrauma Center, Zielona Gora, Poland

Date of Web Publication18-Dec-2017

Correspondence Address:
Dr. Grzegorz Miekisiak
Department of Neurosurgery, Ul. Jana Pawla II 2, 57-320 Polanica-Zdroj
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EJSS.EJSS_15_17

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Background and Objective: Spinal surgery becomes ever safer and the success rate is constantly increasing. Nevertheless many patients present poor outcomes despite apparent technical success. Proper selection of patients is key, but it is virtually impossible to provide a clear algorithm as there are great many aspects to be considered. The purpose of this study was to assess the potential of anonymous web surveys as screening tools for factors predicting poor outcomes of surgery. The hypothesis was that frequent users of health-care services (FUOHS) are worse surgical candidates. Methods: An open anonymous and interactive web surveys were placed within a web portal concerning the spinal health. It was comprised of three sections: first one focused on demographics and information regarding the surgery, second being the Core Outcome Measures Index questionnaire, and the third containing additional information. Results: A total of 425 subjects completed the questionnaire. After removing multiple entries, the final number of subjects included in the study was 411. The relative risk of an unfavorable outcome in a FUOHS group was 3.63 compared with the rest. Likewise, the relative risk of reporting complications in this group was 1.94 though it reached the statistical significance only in the subgroup of patients who had a surgery on a lumbar segment. Discussion and Conclusions: The web surveys can help identify factors that can predict bad outcomes of surgical treatment. In this case, it was shown that frequent visits to doctors' office for reasons other than spine-related is a negative prognostic factor for good outcome of spine surgery.

Keywords: Complications, hypochondriasis, outcomes, predictors of outcome, spine surgery

How to cite this article:
Miekisiak G, Latka D, Jarmuzek P. Frequent users of health-care services have worse outcomes of spinal surgery: Results from a web-based survey. J Spinal Stud Surg 2017;1:51-5

How to cite this URL:
Miekisiak G, Latka D, Jarmuzek P. Frequent users of health-care services have worse outcomes of spinal surgery: Results from a web-based survey. J Spinal Stud Surg [serial online] 2017 [cited 2022 Dec 2];1:51-5. Available from: https://www.jsss-journal.com/text.asp?2017/1/3/51/221106

  Introduction Top

Despite the advances in spinal surgery, about 20%–40% of the patients exhibit poor outcome regardless of the technical success of the procedure.[1] These relatively high numbers of patients have been derived largely from the studies reporting the outcome measures. For many years, the primary sources of outcomes data were clinician-based but were eventually superseded by the patient-reported outcome measures.[2] Currently, the patient is considered to be the ultimate referee, and many elements play a significant role in his or her judgment. A number of factors affecting the outcome have been identified, including demographic, medical, psychosocial, and work-related factors.[3] The patients with hypochondriasis and hysteria have proven to be preoccupied with their health, with a tendency to exaggerate their physical symptoms that reveal the worse outcome of a spinal surgery.[4] A simple method of screening for known risk factors could optimize the planned surgical treatment.

An important aspect of spinal surgery is the presence of complications that have a profound impact on patients' perspective in the outcome assessment. The reporting of complications by the practitioners has been inaccurate for several reasons, one of them being the lack of clear definition.[5] A new approach has recently been proposed, according to which patients can themselves be a reliable source for data relating to the complications that are clinically important, which can influence their satisfaction with the treatment and global outcome.[6] Despite the advantages, this solution also has certain limitations. The patients may underreport complications in an attempt to please the physician.[7] The social desirability response bias is also likely to affect the results.

The primary source of evidence for the risk factors of surgical interventions includes cohort studies in which the patients are followed-up for a sufficient period.[8] These studies take months to years for its completion, and only a limited number of factors can be evaluated at once. To overcome these limitations, the attention has been brought recently on surgical registries, which takes the advantage of the large volume of subjects.[9] This study represents a novel approach. We have developed an advanced, anonymous, and interactive web form. It has been designed to provide outcome information to the patients treated at various sites. The main hypothesis tested was that frequent users of health-care services (FUOHS), i.e., the patients who frequently visit physician's office for reasons other than spinal problems would have worse outcomes. Second, it was hypothesized that the reporting of complications would also be affected by the frequency of visits at the nontreating physician's office.

  Methods Top

The questionnaire

The data were gathered using an interactive questionnaire divided into three sections. The first section contained a series of questions regarding the demographic information. The second enclosed the Core Outcome Measures Index (COMI); a well-established patient-reported outcome measure,[10] adjusted accordingly for each segment of the spine. The overall result was expressed on a 0–10 numeric scale, with 10 being the worst status. The 11th item of the instruments was a direct question regarding the overall success of the treatment (“Overall, how much did the treatment help your back or neck problem?”), with possible answers, such as: “helped a lot,” “helped,” “helped only little,” “didn't help” or “made things worse.” For the purpose of this study, we considered last two answers as the failure of the treatment. The last section contained additional questions, including the number of visits to the doctors' office within the last year, the diagnosis, and the main reason for consenting to surgery. The screenshot is provided in [Figure 1].
Figure 1: Web survey screenshot.

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The questionnaire made use of the HTML/CSS and JQuery technology for the interactive adjustment and validation. The serverside used PHP with MySQL for data handling. Multiple submissions from the same user were identified with cookies. The average time to complete the questionnaire was approximately 12–15 min. The survey was built in compliance with the CHERRIES checklist.[11] The web form was embedded within one of the nations' largest web portals concerning the spinal health, endorsed by the Polish Society of Spinal Surgery. It was advertised on a popular social networking site named Facebook. The study was approved by the ethics committee of the Poznan University of Medical Sciences.

Statistical analysis

The statistical analysis was made using the MedCalc software version (MedCalc Software, Belgium). The differences in the COMI score and age were compared using the t-test for independent samples. The relative risk was calculated using the logistic regression for dichotomous variables. The Chi-square test was used for categorical data (distribution of gender and bad outcomes in each group). Age was compared with the t-test.

  Results Top

Between March 20, 2014 and July 12, 2015, the online questionnaire has been submitted 425 times. Fourteen entries have been identified as multiple submissions by the same users. In these cases, the last submission has been disregarded. Thus, the final number of subjects included in the study was 411. There were 265 women (64.50%) and 146 men (35.5%). Their mean age was 42.64 years (standard deviation = 11.99, range: 18–83 years). The predominant segment of intervention was lumbar, followed by cervical [Table 1]. The most frequent pathology was “discopathy,” followed by “other” and “stenosis” [Table 1]. The vast majority of response was observed at least one year after the last surgery, with the most frequently reported follow-up of 3–12 months [Table 1]. The FUOHS group was well matched with the rest in terms of age and gender distribution [Table 2].
Table 1: Details of pathologies as well as the time of follow-up

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Table 2: Comparison of selected parameters between the groups

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Self-reported outcomes

The chance of poor outcome of surgery was significantly higher in an FUOHS group; the number of respondents in this group was 42. The relative risk of an unfavorable outcome for this subset of subjects within the entire pool was 3.63 (confidence interval [CI] 95% 1.80–7.30, P = 0.001). When considering only surgeries on either cervical or lumbar segment, this value was even higher: 4.41 (CI 95% 2.13–9.13, P = 0.0001). The data are shown in [Figure 2]. The value of COMI was also found to be higher in the FUOHS group (6.88, CI 95% 6.28–7.47) as compared to the rest (5.77, CI 95% 5.52–6.01). The difference was statistically significant, P < 0.005 [Figure 3].
Figure 2: The relative risk of poor outcome in the relationship with the number of visits.

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Figure 3: The relative risk of reported complications in the relationship with the number of visits.

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Patient-reported complication rate

There was a total of 112 complications reported by 105 respondents. The details are shown in [Table 3]. The relative risk of having complications was higher in the case of FUOHS group. For all respondents, the relative risk of reporting a complication was 1.94, but it did not reach the statistical significance level (CI 95% 0.99–3.77, P = 0.06). On the other hand, when considering the subset of respondents who underwent surgery on the cervical or lumbar spine the RR was 2.48, and it was statistically significant (CI 95% 1.23–4.98, P = 0.01).
Table 3: Distribution of patients with reported complications

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  Discussion Top

Despite the remarkable progress in understanding the spinal pathology, surgeons are often puzzled by the poor outcomes even with evident technical success. A number of psychosocial factors affecting the patient-reported outcomes have been proposed, such as depression,[12] compensation status,[13] and work-related disability.[14]

The study results proved that a single element in the patients' past medical history, namely, the high number of visits to the physician's office for reasons other than spinal disease, is likely to identify patients at higher risk of poor outcome. It has been demonstrated that the cutoff value for visits is ten or more in the year preceding the surgery. The respondents in this group were nearly 4 times more likely to report a failure of treatment. This finding is not surprising in view of the literature associated with hypochondriasis with poor outcomes.[15] This treatment of latent is very difficult to screen and requires complicated psychometric testing.[16]

Interestingly, the same group of respondents was significantly more prone to report complications of surgical treatment. In this case, the effect was not so strong, and it only reached statistical significance in the group of respondents who underwent surgery of the lumbar segment. Again, this finding is perfectly rational given the fact that the majority of complications are highly subjective,[17] and therefore, more likely to be reported by patients heavily preoccupied with their health status.

COMI was used as the main PROM in the present study as a relatively short but robust instrument of proven validity. Its favorable psychometric properties have been described in previous studies.[10],[18],[19] The main advantage of this questionnaire lies in its brevity, reducing the burden on the patients and practitioners. It is also well suited for the online administration. However, this instrument is considered to be accurate and sensitive for spinal disorders and can be argued whether it sufficiently addresses the complications such as anxiety and depression. Recently, a modified questionnaire (COMIAD) have been proposed, with two additional questions focused on these issues.[20]

The COMI is unique in one aspect. One of the questions directly asks for complications: “whether they occurred, and if so – what is its nature?” This allows the patients to be the sole judges of the inadvertent event during their treatment. Lattig et al.[21] showed that the patients and surgeons often disagree, and some practitioners have a tendency to disregard some clinically important side effects of their treatment. One may argue that the patient-reported complications are highly subjective, but on the other hand, these are clinically relevant as they have an impact on the overall outcome as opposed to some inadvertent events reported by the physicians.

This study is based on the data obtained from an anonymous web survey posted on an open site. This approach was selected to provide full anonymity that would not be possible in any other conceivable way. Clear advantages of web forms over personal interviews would come from denying an important bias of social desirability.[22] It is particularly significant in this setting. It has been shown that patients may underreport poor in an effort to please their physician; fearing this would negatively affect further treatment.[23] Therefore, the web survey may represent an unbiased approach, providing more objective results than personal interviews.[4]

Study limitations

With such open surveys, there is a risk of nonserious responses. This issue has been raised in the past, and many authors claim its negligible effect on the results.[24] Indeed, the analysis of segments treated and procedures performed mirrors the case mix encountered in most practices. Likewise, the distribution of complications reported by the subjects matches the data reported elsewhere.[6]

It is almost inevitable that the study was affected by some sample selection bias. One may assume that patients who are not satisfied with their treatment are more likely to seek information on the internet on spinal health, and thus, should be overrepresented in the present study, with the dissatisfied patients comprising a little <16%. Surprisingly, this value is even lower than the reported value in a large, registry-based study (29%) as analyzed by Grob and Mannion.[6]

Based on the presented data, it is not possible to discern whether more frequent visits to doctor's office were the result of poor health, and thus, inevitably led to worse outcomes. This study has shown that such element in the past medical history is associated with increased risk of failure.

  Conclusions Top

The web surveys can help identify factors that can predict bad outcomes of surgical treatment. As the number of such factors is great, these simple and inexpensive instruments may be used as screening tools.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mannion AF, Elfering A. Predictors of Surgical Outcome. Berlin, Heidelberg: Springer Berlin Heidelberg; 2008.  Back to cited text no. 1
Patel MS, Newey M, Sell P. A comparison of patient-reported outcome measures after spinal surgery. Bone Joint J 2015;97-B:366-71.  Back to cited text no. 2
Mannion AF, Elfering A, Staerkle R, Junge A, Grob D, Dvorak J, et al. Predictors of multidimensional outcome after spinal surgery. Eur Spine J 2007;16:777-86.  Back to cited text no. 3
Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976) 2000;25:2616-21.  Back to cited text no. 4
Fritzell P, Hägg O, Nordwall A; Swedish Lumbar Spine Study Group. Complications in lumbar fusion surgery for chronic low back pain: Comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J 2003;12:178-89.  Back to cited text no. 5
Grob D, Mannion AF. The patient's perspective on complications after spine surgery. Eur Spine J 2009;18 Suppl 3:380-5.  Back to cited text no. 6
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Sinikallio S, Aalto T, Airaksinen O, Lehto SM, Kröger H, Viinamäki H, et al. Depression is associated with a poorer outcome of lumbar spinal stenosis surgery: A two-year prospective follow-up study. Spine (Phila Pa 1976) 2011;36:677-82.  Back to cited text no. 12
Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: A meta-analysis. JAMA 2005;293:1644-52.  Back to cited text no. 13
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Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32:843-53.  Back to cited text no. 16
Mannion AF, Fekete TF, O'Riordan D, Porchet F, Mutter UM, Jeszenszky D, et al. The assessment of complications after spine surgery: Time for a paradigm shift? Spine J 2013;13:615-24.  Back to cited text no. 17
Mannion AF, Porchet F, Kleinstück FS, Lattig F, Jeszenszky D, Bartanusz V, et al. The quality of spine surgery from the patient's perspective: Part 2. Minimal clinically important difference for improvement and deterioration as measured with the core outcome measures index. Eur Spine J 2009;18 Suppl 3:374-9.  Back to cited text no. 18
Mannion AF, Porchet F, Kleinstück FS, Lattig F, Jeszenszky D, Bartanusz V, et al. The quality of spine surgery from the patient's perspective. Part 1: The core outcome measures index in clinical practice. Eur Spine J 2009;18 Suppl 3:367-73.  Back to cited text no. 19
Cedraschi C, Marty M, Courvoisier DS, Foltz V, Mahieu G, Demoulin C, et al. Core outcome measure index for low back patients: Do we miss anxiety and depression? Eur Spine J 2016;25:265-74.  Back to cited text no. 20
Lattig F, Grob D, Kleinstueck FS, Porchet F, Jeszenszky D, Bartanusz V, et al. Ratings of global outcome at the first post-operative assessment after spinal surgery: How often do the surgeon and patient agree? Eur Spine J 2009;18 Suppl 3:386-94.  Back to cited text no. 21
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Gosling SD, Vazire S, Srivastava S, John OP. Should we trust web-based studies? A comparative analysis of six preconceptions about internet questionnaires. Am Psychol 2004;59:93-104.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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