Patient preferences for treatment of lumbar disc herniation: a discrete choice experiment

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  • 1 Department of Neurosurgery, Park MC, Rotterdam, The Netherlands;
  • | 2 Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork-Presbyterian Hospital, New York, New York;
  • | 3 Erasmus Choice Modelling Centre and
  • | 4 Erasmus School of Health Policy and Management, Erasmus University Rotterdam, The Netherlands;
  • | 5 Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands;
  • | 6 Department of Human Movement Sciences, Faculty Behavioral and Movement Sciences and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; and
  • | 7 Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, The Netherlands
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OBJECTIVE

Lumbar discectomy is a frequently performed procedure to treat sciatica caused by lumbar disc herniation. Multiple surgical techniques are available, and the popularity of minimally invasive surgical techniques is increasing worldwide. Clinical outcomes between these techniques may not show any substantial differences. As lumbar discectomy is an elective procedure, patients’ own preferences play an important role in determining the procedure they will undergo. The aims of the current study were to determine the relative preference weights patients apply to various attributes of lumbar discectomy, determine if patient preferences change after surgery, identify preference heterogeneity for choosing surgery for sciatica, and calculate patient willingness to pay for other attributes.

METHODS

A discrete choice experiment (DCE) was conducted among patients with sciatica caused by lumbar disc herniation. A questionnaire was administered to patients before they underwent surgery and to an independent sample of patients who had already undergone surgery. The DCE required patients to choose between two surgical techniques or to opt out from 12 choice sets with alternating characteristic levels: waiting time for surgery, out-of-pocket costs, size of the scar, need of general anesthesia, need for hospitalization, effect on leg pain, and duration of the recovery period.

RESULTS

A total of 287 patients were included in the DCE analysis. All attributes, except scar size, had a significant influence on the overall preferences of patients. The effect on leg pain was the most important characteristic in the decision for a surgical procedure (by 44.8%). The potential out-of-pocket costs for the procedure (28.8%), the wait time (12.8%), need for general anesthesia (7.5%), need for hospitalization (4.3%), and the recovery period (1.8%) followed. Preferences were independent of the scores on patient-reported outcome measures and baseline characteristics. Three latent classes could be identified with specific preference patterns. Willingness-to-pay was the highest for effectiveness on leg pain, with patients willing to pay €3133 for a treatment that has a 90% effectiveness instead of 70%.

CONCLUSIONS

Effect on leg pain is the most important factor for patients in deciding to undergo surgery for sciatica. Not all proposed advantages of minimally invasive spine surgery (e.g., size of the scar, no need of general anesthesia) are necessarily perceived as advantages by patients. Spine surgeons should propose surgical techniques for sciatica, not only based on own ability and proposed eligibility, but also based on patient preferences as is part of shared decision making.

ABBREVIATIONS

COMI-back = Core Outcome Measures Index for back pain; DCE = discrete choice experiment; MNL = multinomial logit; NRS = numeric rating scale; OM = open microdiscectomy; PELD = percutaneous endoscopic lumbar discectomy; PTED = percutaneous transforaminal endoscopic discectomy.

Supplementary Materials

    • Supplementary Table 1 (PDF 401 KB)

Illustration from Lee et al. (pp 822–829). Copyright Sun Joo Kim. Published with permission.

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