Document Type: RESEARCH PAPER
Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
Background: When the best treatment option is uncertain, a patient’s preference based on personal values should be
the source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation in
treatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patient
Methods: A total of 184 surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operative
treatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment.
To test the influence of six specific patient preferences the preference was randomly assigned to each scenario in an
affirmative or negative manner. Surgeon characteristics were collected for each participant.
Results: Of the six preferences studied, four influenced surgeon recommendations. Surgeons were more likely
to recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR,
0.82; 95% CI, 0.71 – 0.94; P=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 – 0.95;
P=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 – 1.3; P=0.046), and when patients
only preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option
(adjusted OR, 0.78; 95% CI, 0.68 – 0.89; P<0.001).
Conclusion: Patient preferences were found to have a measurable influence on surgeon treatment recommendations
though not as much as we expected-and surgeons on average interpreted surgery as more aesthetic. This emphasizes
the importance of strategies to help patients reflect on their values and ensure their preferences are consistent with
those values (e.g. use of decision-aids).
Level of evidence: III