Key drivers of patient satisfaction in lumbar spine surgery

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

The relationship of perceived empathy with levels of pain intensity and incapability among patients visiting a musculoskeletal specialist

BACKGROUND

People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them.

OBJECTIVE

This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist.

PATIENT INVOLVEMENT

After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy.

RESULTS

Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r = -0.16) lower pain intensity in bivariate and multivariable analyses.

DISCUSSION

People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic.

PRACTICAL VALUE

Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.

Patient satisfaction after multiple revision surgeries for adult spinal deformity

OBJECTIVE

Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores.

METHODS

This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society-22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index.

RESULTS

In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis.

CONCLUSIONS

Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.

The Effect of the Severity of Preoperative Leg Pain on Patient-Reported Outcomes, Minimum Clinically Important Difference Achievement, and Patient Satisfaction After Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

To compare patient-reported outcome measures (PROMs), satisfaction, and minimum clinically important difference (MCID) achievement after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in patients stratified by preoperative leg pain.

METHODS

Patients undergoing MIS-TLIF were collected through retrospective review of a prospectively maintained single-surgeon database. PROMs administered preoperatively/postoperatively included Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) back/leg pain, Oswestry Disability Index (ODI), and 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS). Patients were grouped based on preoperative VAS leg scores: VAS leg ≤7 or VAS leg >7. Inferential statistics were used to compare PROMs, MCID achievement rates, and postoperative satisfaction between groups.

RESULTS

A total of 562 patients were eligible (168 VAS leg score ≤7; 394 VAS leg score >7). Significant differences between cohorts in postoperative mean PROMs were noted for PROMIS-PF at 6 weeks/2 years, SF-12 PCS at 6 weeks/2 years, SF-12 MCS at 6 weeks/12 weeks/6 months/1 year, VAS back score at 6 weeks/12 weeks/6 months, VAS leg score at 6 weeks/12 weeks/6 months/2 years and ODI at all postoperative time points (P < 0.045, all). In the VAS leg score >7 cohort, a greater proportion achieving MCID for VAS leg score at all postoperative time points and ODI at 12 weeks (P < 0.010, all). Postoperative satisfaction was greater in VAS back score ≤7 cohort for VAS leg score at 6 weeks/12 weeks/6 months/2 years, VAS back score at 12 weeks/2 years, and ODI at 6 weeks/12 weeks/6 months/2 years (P < 0.046, all).

CONCLUSIONS

Patients with severe preoperative leg pain showed worse postoperative PROM scores and patient satisfaction for disability and back/leg pain. MCID achievement rates across cohorts were similar. Patients with severe leg pain may have expectations for surgical benefits incongruent with their postoperative outcomes, and physicians may seek to manage the preoperative expectations of their patients to reflect likely outcomes after MIS-TLIF.

Postoperative Physical Therapy Program Focused on Low Back Pain Can Improve Treatment Satisfaction after Minimally Invasive Lumbar Decompression

Patient satisfaction is crucial in pay-for-performance initiatives. To achieve further improvement in satisfaction, modifiable factors should be identified according to the surgery type. Using a prospective cohort, we compared the overall treatment satisfaction after microendoscopic lumbar decompression between patients treated postoperatively with a conventional physical therapy (PT) program (control; n = 100) and those treated with a PT program focused on low back pain (LBP) improvement (test; n = 100). Both programs included 40 min outpatient sessions, once per week for 3 months postoperatively. Adequate compliance was achieved in 92 and 84 patients in the control and test cohorts, respectively. There were no significant differences in background factors; however, the patient-reported pain score at 3 months postoperatively was significantly better, and treatment satisfaction was significantly higher in the test than in the control cohort (−0.02 ± 0.02 vs. −0.03 ± 0.03, p = 0.029; 70.2% vs. 55.4%, p = 0.045, respectively). In the multivariate logistic regression analysis, patients treated with the LBP program tended to be more satisfied than those treated with the conventional program, independent of age, sex, and diagnosis (adjusted odds ratio = 2.34, p = 0.012). Postoperative management with the LBP program could reduce pain more effectively and aid spine surgeons in achieving higher overall satisfaction after minimally invasive lumbar decompression, without additional pharmacological therapy.

Female Gender Is Associated with Lower Satisfaction with Postoperative Telemedicine Visits in Sports Medicine

Introduction: Telemedicine is a relatively new adjunct in orthopedic care but it has emerged from the periphery, driven in part by the COVID-19 pandemic. Although it has drastically increased in use, little is known of the factors that drive satisfaction with telemedicine. The purpose of the current study was to evaluate the patient's satisfaction with postoperative telemedicine visits in those undergoing knee or shoulder arthroscopy, and to analyze the factors associated with satisfaction with telemedicine. Methods: A prospective study was performed to evaluate satisfaction comparing postoperative telemedicine and in-office visits, in those undergoing shoulder and knee arthroscopy. Multiple factors were analyzed for correlation with satisfaction via multi-linear regression, including demographics such as gender, education, age, and race. Patients were also evaluated for preference for future visits with reference to the group in which they were placed. Results: Overall, 215 patients were included with a subgroup analysis of 93 patients receiving telemedicine visits. Patients reported overall similar satisfaction with telemedicine visits after shoulder and knee arthroscopy, with a high level of satisfaction seen in both. Female sex was found to be associated with decreasing satisfaction with telemedicine visits (p = 0.036). In addition, as a whole, the cohort was found to prefer future visits to be the same as the group they were placed in, but females statistically did not have this preference for their familiar group and were skewed toward the preference of in-person visits (p = 0.377). Conclusions: Our study found that female patients were less likely to be satisfied with postoperative telemedicine visits after knee or shoulder arthroscopy. Further, females were also less likely to indicate preference for future telemedicine visits. In contrast, education, history of prior surgery, age, and race were not associated with postoperative satisfaction.

Reducing Postoperative Opioid-prescribing Following Posterior Lumbar Fusion Does Not Significantly Change Patient Satisfaction

STUDY DESIGN

Retrospective comparative; LOE-3.

OBJECTIVE

The purpose of this study was to investigate what effect, if any, an institutional opioid reduction prescribing policy following one- or two-level lumbar fusion has on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results.

SUMMARY OF BACKGROUND DATA

Previous research has demonstrated that high levels of opioid-prescribing may be related, in part, to a desire to produce superior patient satisfaction.

METHODS

A retrospective review of prospectively collected data was conducted on patients who underwent one- or two-level lumbar fusions L3-S1 between October 2014 and October 2019 at a single institution. Patients with complete survey information were included in the analysis. Patients with a history of trauma, fracture, spinal deformity, fusions more than two levels, or prior lumbar fusion surgery L3-S1 were excluded. Cohorts were based on date of surgery relative to implementation of an institutional opioid reduction policy, which commenced in October 1, 2018. To better compare groups, opioid prescriptions were converted into milligram morphine equivalents (MME).

RESULTS

A total of 330 patients met inclusion criteria: 259 pre-protocol, 71 post-protocol. There were 256 one-level fusions and 74 two-level fusions included. There were few statistically significant differences between groups with respect to patient demographics (P > 0.05) with the exception of number of patients who saw the pain management service, which increased from 36.7% (95) pre-protocol to 59.2% (42) post-protocol; P < 0.001. Estimated blood loss (EBL) decreased from 533 ± 571 mL to 346 ± 328 mL (P = 0.003). Percentage of patients who underwent concomitant laminectomy decreased from 71.8% to 49.3% (P < 0.001). Average opioids prescribed on discharge in the pre-protocol period was 534 ± 425 MME, compared to after initiation of the protocol, that is 320 ± 174 MME (P < 0.001). There was no statistically significant difference with respect to satisfaction with pain control, 4.49 ± 0.85 pre-protocol versus 4.51 ± 0.82 post-protocol (P = 0.986).

CONCLUSION

A reduction in opioids prescribed at discharge after one- or two-level lumbar fusion is not associated with any statistically significant change in patient satisfaction with pain management, as measured by the HCAHPS survey.Level of Evidence: 3.

Patient Satisfaction Is Equivalent Using Telemedicine Versus Office-Based Follow-up After Arthroscopic Meniscal Surgery: A Prospective, Randomized Controlled Trial

BACKGROUND

Telemedicine has increasingly been considered as a viable alternative to traditional office-based health care, including postoperative follow-up visits. The purpose of the present study was to determine if patient satisfaction with overall care is equivalent for telemedicine follow-up (i.e., synchronous face-to-face video) and office-based follow-up after arthroscopic meniscectomy and repair.

METHODS

Patients were prospectively enrolled from August 1, 2019, to March 1, 2020. Patients were included who were ≥18 years old, consented to isolated arthroscopic meniscal repair or meniscectomy, and were able to properly utilize telemedicine software on a computer, tablet, or smartphone with a built-in camera. Patient demographic data, including complication events and postoperative satisfaction data, were recorded and analyzed for significance.

RESULTS

One hundred and fifty patients were enrolled in the study, of whom 122 (81.3%) were included in the final analysis. There were no significant differences between groups in terms of patient demographics or satisfaction scores. Patient satisfaction with overall care was equivalent based on the results of two 1-sided t-test analysis for equivalence (9.77 ± 0.60 in the office-based group versus 9.79 ± 0.53 in the telemedicine group; p < 0.001). When patients were asked to indicate their preferred follow-up type with the options listed as the type they received versus an alternative, 58 patients (84.1%) in the office-based group preferred their received type of follow-up, whereas 42 (79.2%) in the telemedicine group preferred their received follow-up (p = 0.493). There were no significant differences between groups in terms of complications (p > 0.05).

CONCLUSIONS

The present study showed that patient satisfaction with overall care is equivalent between telemedicine and office-based follow-up in the immediate postoperative period following an arthroscopic meniscal surgical procedure, and should be considered a reasonable alternative to the traditional in-office modality.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Key drivers of patient satisfaction with spine surgeons in the outpatient setting

OBJECTIVE

The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) was developed as a result of the value-based purchasing initiative by the Center for Medicare & Medicaid Services. It allows patients to rate their experience with their provider in the outpatient setting. These ratings are then reported in aggregate and made publicly available, allowing patients to make informed choices during physician selection. In this study, the authors sought to elucidate the primary drivers of patient satisfaction in the office-based spine surgery setting as represented by the CG-CAHPS.

METHODS

All patients who underwent lumbar spine surgery between 2009 and 2017 and completed a patient experience survey were studied. The satisfied group comprised patients who selected a top-box score (9 or 10) for overall provider rating (OPR) on the CG-CAHPS, while the unsatisfied group comprised the remaining patients. Demographic and surgical characteristics were compared using the chi-square test for categorical variables and the Student t-test for continuous variables. A multivariable logistic regression model was developed to analyze the association of patient and surgeon characteristics with OPR. Survey items were then added to the baseline model individually, adjusting for covariates.

RESULTS

The study population included 647 patients who had undergone lumbar spine surgery. Of these patients, 564 (87%) selected an OPR of 9 or 10 on the CG-CAHPS and were included in the satisfied group. Patient characteristics were similar between the two groups. The two groups did not differ significantly regarding patient-reported health status measures. After adjusting for potential confounders, the following survey items were associated with the greatest odds of selecting a top-box OPR: did this provider show respect for what you had to say? (OR 21.26, 95% CI 9.98-48.10); and did this provider seem to know the important information about your medical history? (OR 20.93, 95% CI 11.96-45.50).

CONCLUSIONS

The present study sought to identify the key drivers of patient satisfaction in the postoperative office-based spine surgery setting and found several important associations. After adjusting for potential confounders, several items relating to physician communication were found to be the strongest predictors of patient satisfaction. This highlights the importance of effective communication in the patient-provider interaction and elucidates avenues for quality improvement efforts in the spine care setting.

Variations in Patient Satisfaction Scores Between HCAHPS and a Novel Orthopedic Practice-Specific Survey

Performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey can affect up to 33% of a physician's reimbursement from the Centers for Medicare & Medicaid Services. At this pseudo-private orthopedic practice, the authors characterized how physicians often achieve drastically different scores between HCAHPS and an Internal Patient Satisfaction Questionnaire (IPSQ). Eighteen physicians were ranked separately according to percentage of top-box scores on HCAHPS and IPSQ. There was an inverse relationship between physician rank for the 2 surveys according to Spearman correlation coefficient (ρ = -0.36, P = .15). Qualitative subanalysis indicated that although "physician interaction" was the most common reason for negative comments on HCAHPS, "ancillary staff" and "workflow" concerns were common on IPSQ. The outpatient setting remains a critical component in achieving high-quality orthopedic care. Consequently, HCAHPS alone may not be a sufficient indicator of patient satisfaction for orthopedic and other subspecialty practices.

Patient-Reported Outcomes: Quality of Care on a Neurosurgical Ward

BACKGROUND AND OBJECTIVES

Patient experience has become a quality measure in hospitals across the United States. To improve our understanding of our neurosurgical patient population's satisfaction needs, we undertook a detailed survey to identify areas of needed improvement.

METHODS

Upon institutional review board approval, a detailed survey adopted from the Swedish quality-of-care patient questionnaire was distributed to all patients being discharged from the neurosurgical ward over a month period. From June 2014 to July 2014, all patients admitted to the neurosurgery service through the emergency department, clinic, or other facilities were enrolled. There were no specific inclusion criteria except for age older than 18 years, intact cognition to complete the survey, and return of a completed survey. Data were collected in 6 major categories, including information availability, patient accessibility, treatment received, caring perception, hospital environment, and overall satisfaction. Patients were evaluated by age, gender, surgery, and admission type.

RESULTS

Our analysis demonstrated an improved overall satisfaction in those patients being admitted electively from the clinic as compared with emergency department admissions or hospital transfers. In addition, patients admitted on an emergent basis reported a lower satisfaction pertaining to receiving information, specifically test results.

CONCLUSIONS

Emergent admissions represent a subpopulation that may require additional strategies to improve patient satisfaction survey scores.

Predictors of Patient Satisfaction in Spine Surgery: A Systematic Review

BACKGROUND

Recently, there has been increased interest in patient satisfaction measures such as Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. In this systematic review, the spine surgery literature is analyzed to evaluate factors predictive of patient satisfaction as measured by these surveys.

METHODS

A thorough literature search was performed in PubMed/MEDLINE, Google Scholar, and Cochrane databases. All English-language articles from database inception to July 2020 were screened for study inclusion according to PRISMA guidelines.

RESULTS

Twenty-four of the 1899 published studies were included for qualitative analysis. There has been a statistically significant increase in the number of publications across years (P = 0.04). Overall, the studies evaluated the relationship between patient satisfaction and patient demographics (71%), preoperative and intraoperative clinical factors (21%), and postoperative factors (33%). Top positive predictors of patient satisfaction were patient and nursing/medical staff relationship (n = 4; 17%), physician-patient relationship (n = 4; 17%), managerial oversight of received care (n = 3; 13%), same sex/ethnicity between patient and physician (n = 2; 8%), and older age (n = 2; 8%). Top negative predictors of patient satisfaction were high Charlson Comorbidity Index/high disability/worse overall health functioning (n = 7; 29%), increased length of hospital stay (n = 4; 17%), high rating for pain/complications/readmissions (n = 4; 17%), and psychosocial factors (n = 3; 13%).

CONCLUSIONS

There is heterogeneity in terms of different factors, both clinical and nonclinically related, that affect patient satisfaction ratings. More research is warranted to investigate the role of hospital consumer surveys in the spine surgical patient population.

Patient Expectations of Adult Spinal Deformity Correction Surgery

BACKGROUND

There is a growing interest in examining preoperative expectations as a potential predictor of postoperative outcome. However, it has never been studied in the setting of adult spinal deformity (ASD). This study aims to characterize patient expectations before ASD surgery and examine the relationship between preoperative expectation and postoperative patient-reported outcomes (PROs).

METHODS

Analysis of prospectively collected clinical and PRO data was performed on patients who underwent ASD surgery. Inclusion criteria were age >18 years, a diagnosis of ASD, >3 vertebral level instrumentation, and completed pre- and postoperative surveys. The preoperative expectation survey included expectations of surgical outcome, pain reduction, complications, and the duration of postoperative recovery. Relationships between patient expectations and PROs were assessed.

RESULTS

Twenty-seven patients who underwent operative management of ASD met the inclusion criteria. In their preoperative survey, 66% of patients expected highly successful surgery, whereas 22% had a moderate expectation of complications. Patients anticipated an average 71% reduction in back pain (range 42%-100%) and 68% reduction in leg pain (range 0%-100%). Patients who met their expectations of leg pain reduction had significantly greater satisfaction scores than those who did not. There were moderate-to-strong positive correlations between preoperative expectation and observed improvement in back pain, leg pain, and mental health.

CONCLUSIONS

While substantial variability in patient expectation exists for the surgical management of ASD, patients anticipated a positive outcome with a significant reduction in pain. Greater postoperative satisfaction was associated with patients who met the expected improvement in leg pain. Preoperative expectation was positively correlated with change in pain and mental health scores.

Systematic review of telemedicine in spine surgery

OBJECTIVE

The use of telemedicine (TM) has long been available, but recent restrictions to hospitals due to the coronavirus disease 2019 (COVID-19) pandemic have accelerated the global implementation of TM. However, evidence on the effectiveness of this technology for the care of spine surgery patients is limited. In this systematic review the authors aimed to examine the current utilization of TM for spine surgery.

METHODS

Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the themes of telemedicine and spine surgery. Included in the search were randomized controlled trials, cohort studies, and case-controlled studies. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

RESULTS

Out of 1463 references from the initial search results, 12 studies met the inclusion criteria. The majority of TM interventions focused on improving perioperative patient communication and patient education by using mobile phone apps, online surveys, or online materials for consent. The studies reported the feasibility of the use of TM for perioperative care and positive user experiences from the patients.

CONCLUSIONS

The current increase in TM adoption due to the COVID-19 crisis presents an opportunity to further develop and validate this technology. Early evidence in the literature supports the use of TM as an adjunct to traditional in-person clinical encounters for certain perioperative tasks such as supplemental patient education and postoperative surveys.

Clinicians' User Experience of Telemedicine in Neurosurgery During COVID-19

BACKGROUND

Restricted access to hospitals due to the 2019 novel coronavirus disease (COVID-19) pandemic has significantly altered practice patterns for elective neurosurgical care. Particularly, telemedicine has become the primary modality of patient visits for nonemergent conditions. This study aimed to characterize user experiences of neurosurgeons and advanced practice providers focusing on perceived utility and barriers of telemedicine in management of elective neurosurgical patients during COVID-19.

METHODS

An online survey was sent to clinicians involved in neurosurgical care using telemedicine with questions focusing on frequency of utilization, duration of patient encounters, benefits of telemedicine, and barriers to current forms of remote patient visits. Survey responses were stratified by clinical position (neurosurgeon vs. advanced practice provider) and subspecialty focus (cranial vs. spinal neurosurgery).

RESULTS

The survey was completed by 14 of 17 eligible clinicians. Respondents included 10 neurosurgeons and 4 APPs with 57% specializing in cranial neurosurgery and 43% specializing in spinal neurosurgery. During the COVID-19 period, 78% of respondents used teleconference/video conference visits multiple times in a week, and 86% planned to continue using telemedicine after the pandemic. The most common barrier for telemedicine was the inability to perform a neurological examination, while the most common perceived benefit was increased convenience for patients.

CONCLUSIONS

During the COVID-19 period, telemedicine was heavily relied on to ensure the continuation of perioperative care for patients with elective neurosurgical pathologies. While clinicians identified numerous barriers for current telemedicine platforms, the use of telemedicine will likely continue, as it has provided unique benefits for patients, clinicians, and hospitals.

The Association Between Physicians' Communication and Patient-Reported Outcomes in Spine Surgery

STUDY DESIGN

Retrospective cohort study using prospectively collected data.

OBJECTIVE

Determine the association between satisfaction with physician communication and patient-reported outcomes in the inpatient spine surgery setting.

SUMMARY OF BACKGROUND DATA

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys measure the patient experience of care and influence reimbursement for hospital systems and providers in the United States. It is not known whether patient satisfaction with physician communication is associated with better outcomes after spine surgery. Therefore, we evaluated the association between patient satisfaction with physician communication on the HCAHPS survey and improvements in validated patient-reported outcomes measures in a spine surgery population.

METHODS

HCAHPS responses were obtained for patients undergoing elective cervical or lumbar spine surgery from 2013 to 2015. Patient-reported health status measures were the primary outcomes, including EuroQol Five Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Visual Analog Scores for Back and Neck Pain (VAS-BP/NP). The association between satisfaction with communication and preoperative to 1 year postoperative changes in each health status measure was evaluated utilizing multivariable linear regression models.

RESULTS

Our study included 648 patients, of which, 479 (74.4%) created our satisfied cohort. Demographically, our two cohorts were similar with regards to preoperative clinical measures; however, the satisfied cohort had a higher self-rating of their mental health (P < 0.01), and overall health (P < 0.01). After adjusting for clinically relevant confounders, our results demonstrated no significant association between satisfaction with physician communication and improvement in EQ-5D (P = 0.312), PDQ (P = 0.498), or VAS pain scores (P = 0.592).

CONCLUSION

Patient satisfaction with physician communication was not associated with 1-year postoperative improvement in EQ-5D, PDQ, and VAS-Pain after spine surgery. These findings do not diminish the importance of effective communication between doctor and patient, but instead suggest that within the spine surgery setting, using only patient experience data may not accurately reflect the true quality of care received during their inpatient stay.

LEVEL OF EVIDENCE

3.

The limited influence of neurosurgeons' behavior on inpatient satisfaction: a retrospective multihospital analysis

OBJECTIVE

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that assesses patient satisfaction, which is an important measure of the quality of hospital care and ultimately the overall hospital rating (OHR). However, the survey covers several elements of patient satisfaction beyond the patient-surgeon interaction. In this study, authors investigated which admission and experience factors had the highest impact on the OHR.

METHODS

This was a retrospective cohort analysis of HCAHPS surveys from patients who, in the period between August 1, 2016, and January 31, 2018, had been discharged from the neurosurgical or orthopedic service at three hospitals serving a single metropolitan area. The top-box score was defined as the highest rating obtainable for each survey question. Baseline admission attributes were obtained, and multivariate logistic regression was used to determine predictors of the top-box OHR.

RESULTS

After application of the inclusion and exclusion criteria, 1470 patients remained in the analysis. Categories on the HCAHPS included OHR, communication, education, environment, pain management, and responsiveness. After excluding identifying questions from the survey and adjusting for subspecialty and hospital, 7 of 17 HCAHPS survey items were significant predictors of OHR. Only 2 of these were related to the surgeon: 1) discharge, "Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?" (OR 5.93, 95% CI 2.52-13.94); and 2) doctor, "Did doctors explain things in a way you could understand?" (OR 2.78, 95% CI 1.73-4.46). The top three strongest correlating items were 1) discharge; 2) nursing, "Did nurses treat you with courtesy and respect?" (OR 3.86, 95% CI 2.28-6.52); and 3) hospital environment, "Were your room and bathroom kept clean?" (OR 2.86, 95% CI 1.96-4.17).

CONCLUSIONS

The study findings demonstrated that there are several nonmodifiable factors (i.e., specialty, experience) and items that are not under the direct purview of the neurosurgeon (e.g., nursing communication, hospital environment) that are significant influences on overall inpatient satisfaction on the HCAHPS survey. Furthermore, components of the survey that ultimately influence the OHR vary across different hospitals. Hence, HCAHPS survey results should be broadly interpreted as a way to make health systems more aware of the overall hospital factors that can improve quality of care and patient experience.

Patient-related Factors and Perioperative Outcomes Are Associated with Self-Reported Hospital Rating after Spine Surgery

BACKGROUND

Since 2013, the Centers for Medicare & Medicaid Services has tied a portion of hospitals' annual reimbursement to patients' responses to the Hospital Consumer Assessment and Healthcare Providers and Systems (HCAHPS) survey, which is given to a random sample of inpatients after discharge. The most general question in the HCAHPS survey asks patients to rate their overall hospital experience on a scale of 0 to 10, with a score of 9 or 10 considered high, or "top-box." Previous work has suggested that HCAHPS responses, which are meant to be an objective measure of the quality of care delivered, may vary based on numerous patient factors. However, few studies to date have identified factors associated with HCAHPS scores among patients undergoing spine surgery, and those that have are largely restricted to surgery of the lumbar spine. Consequently, patient and perioperative factors associated with HCAHPS scores among patients receiving surgery across the spine have not been well elucidated.

QUESTIONS/PURPOSES

Among patients undergoing spine surgery, we asked if a "top-box" rating on the overall hospital experience question on the HCAHPS survey was associated with (1) patient-related factors present before admission; (2) surgical variables related to the procedure; and/or (3) 30-day perioperative outcomes.

METHODS

Among 5517 patients undergoing spine surgery at a single academic institution from 2013 to 2017 and who were sent an HCAHPS survey, 27% (1480) returned the survey and answered the question related to overall hospital experience. A retrospective, comparative analysis was performed comparing patients who rated their overall hospital experience as "top-box" with those who did not. Patient demographics, comorbidities, surgical variables, and perioperative outcomes were compared between the groups. A multivariate logistic regression analysis was performed to determine patient demographics, comorbidities, and surgical variables associated with a top-box hospital rating. Additional multivariate logistic regression analyses controlling for these variables were performed to determine the association of any adverse event, major adverse events (such as myocardial infarction, pulmonary embolism), and minor adverse events (such as urinary tract infection, pneumonia); reoperation; readmission; and prolonged hospitalization with a top-box hospital rating.

RESULTS

After controlling for potential confounding variables (including patient demographics), comorbidities that differed in incidence between patients who rated the hospital top-box and those who did not, and variables related to surgery, the patient factors associated with a top-box hospital rating were older age (compared with age ≤ 40 years; odds ratio 2.2, [95% confidence interval 1.4 to 3.4]; p = 0.001 for 41 to 60 years; OR 2.5 [95% CI 1.6 to 3.9]; p < 0.001 for 61 to 80 years; OR 2.1 [95% CI 1.1 to 4.1]; p = 0.036 for > 80 years), and being a man (OR 1.3 [95% CI 1.0 to 1.7]; p = 0.028). Further, a non-top-box hospital rating was associated with American Society of Anesthesiologists Class II (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.024), Class III (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.020), or Class IV (OR 0.2 [95% CI 0.1 to 0.5]; p = 0.003). The only surgical factor positively associated with a top-box hospital rating was cervical surgery (compared with lumbar surgery; OR 1.4 [95% CI 1.1 to 1.9]; p = 0.016), while nonelective surgery (OR 0.5 [95% CI 0.3 to 0.8]; p = 0.004) was associated with a non-top-box hospital rating. Controlling for the same set of variables, a non-top-box rating was associated with the occurrence of any adverse event (OR 0.5 [95% CI 0.3 to 0.7]; p < 0.001), readmission (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.023), and prolonged hospital stay (OR, 0.6 [95% CI 0.4 to 0.8]; p = 0.004).

CONCLUSIONS

Identifying patient factors present before surgery that are independently associated with HCAHPS scores underscores the survey's limited utility in accurately measuring the quality of care delivered to patients undergoing spine surgery. HCAHPS responses in the spine surgery population should be interpreted with caution and should consider the factors identified here. Given differing findings in the literature regarding the effect of adverse events on HCAHPS scores, future work should aim to further characterize this relationship.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The true penalty of the waiting room: the role of wait time in patient satisfaction in a busy spine practice

OBJECTIVE

Most clinics collect routine data on performance metrics on physicians for outpatient visits. However, the relationship of these metrics with patient experience is unclear. The goal of this study was to investigate the relationships between the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS), the standard patient experience survey, and clinic performance metrics to understand the determinants of patient satisfaction and identify targets for improving patient experience.

METHODS

The authors performed a retrospective single-institution cohort review of spine surgeon metrics over 15 months including demographics, waiting-room times, in-room times, lead times, timely note closure, timely MyChart responses, and monthly patient volume. Kruskal-Wallis tests and mixed-model regression were used to determine the predictors of 3 domains of patient satisfaction-Global, Access, and Communication.

RESULTS

Over 15 months, 22 surgeons conducted 27,090 visits. The average clinic visit total time was 85.17 ± 25.75 minutes. Increased wait times were associated with poor Global (p = 0.008), Access (p < 0.001), and Communication scores (p = 0.003) in univariate analysis. Every 10-minute increase in waiting time was associated with a 3%, 9.8%, and 2.4% decrease in Global, Access, and Communication scores, respectively. Increased in-room time was also an independent predictor of poor Access scores (p < 0.001). In multivariate analysis, increased wait times were negative predictors of Global (p = 0.005), Access (p < 0.001), and Communication (p = 0.002) scores.

CONCLUSIONS

Excessive waiting-room time significantly impacts unexpected dimensions of the patient experience and impacts communication with patients. Understanding the complex relationship between the factors that inform the patient experience will help target effective interventions to improve clinic efficiency and patient satisfaction.

Predictors of patient satisfaction and survey participation after spine surgery: a retrospective review of 17,853 consecutive spinal patients from a single academic institution. Part 1: Press Ganey

OBJECTIVEPress Ganey surveys are common modalities used to assess patient satisfaction scores in an outpatient setting. Despite the existence of data, neurosurgical and orthopedic literature on patient satisfaction following spinal surgery is scarce.METHODSA total of 17,853 patients who underwent spinal procedures at the authors' institution were analyzed retrospectively for Press Ganey survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1936 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.RESULTSMale patients, patients with urgent/emergency procedures, and patients with longer length of stay (LOS) were less likely to fill out Press Ganey surveys (OR 0.822, p < 0.001; OR 0.781, p = 0.010; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with Press Ganey participation (OR 0.907, p = 0.055). Patients undergoing fusion procedures were more likely to participate in Press Ganey surveys (OR 1.419, p < 0.001). Of the patients who filled out surveys, there were no positive predictors associated with receiving perfect scores on Press Ganey surveys. High Charlson Comorbidity Index (OR 0.959, p = 0.02), increasing elapsed time since surgery or discharge (OR 0.996, p = 0.03), and increasing LOS (OR 0.965, p = 0.009) were all negatively associated with receiving a perfect score. Patients who underwent a posterior-approach procedure compared with other approaches were less likely to report a low Press Ganey score (OR 0.297, p = 0.046). Patient sex and race did not influence the likelihood of receiving perfect or low Press Ganey scores. Finally, the perceived skill of the surgeon was not a significant predictor for perfect (p > 0.99) or low (p = 0.828) Press Ganey scores.CONCLUSIONSPatient participation in Press Ganey surveys strongly correlated with preoperative factors such as procedure approach and type, as well as postoperative factors such as LOS and complications. No factors were associated with an increased likelihood of receiving a perfect Press Ganey score. Similarly, LOS and time elapsed since surgery to survey completion were significant negative predictors of perfect Press Ganey scores. Skill of surgeon, sex, and race did not correlate with a predictive value for Press Ganey outcomes. In addition, overall comorbid disease burden was found to be a significant negative predictor for high patient satisfaction scores. Further study on predictors of patient satisfaction within spine surgery is needed to better assist physicians in improving the surgical experience for patients.

Predictors of patient satisfaction and survey participation after spine surgery: a retrospective review of 17,853 consecutive spinal patients from a single academic institution. Part 2: HCAHPS

OBJECTIVEPatient satisfaction is a new and important metric in the American healthcare system. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a common modality used to assess patient satisfaction in inpatient settings. Despite the existence of data, neurosurgical literature on patient satisfaction following spinal surgery is scarce.METHODSA total of 17,853 patients who underwent spinal procedures at the authors' institution were analyzed retrospectively for HCAHPS survey participation. Appropriate demographic, surgical, comorbidity, and complication data were collected; 1118 patients had patient satisfaction survey data, and further survey metrics were collected for this subset of patients.RESULTSMale patients, patients with urgent/emergency procedures, and patients with a longer length of stay were less likely to complete an HCAHPS survey (OR 0.820, p < 0.001; OR 0.818, p = 0.042; and OR 0.983, p < 0.001, respectively). Posterior approach was negatively associated with HCAHPS survey participation (OR 0.868, p = 0.007). Patients undergoing fusion procedures were more likely to participate in HCAHPS surveys (OR 1.440, p < 0.001). Of the completed HCAHPS surveys, there were no positive predictors associated with perfect scores. High Charlson Comorbidity Index (OR 0.931, p = 0.007), increasing elapsed time since surgery or discharge (OR 0.992, p = 0.004), and increasing length of stay (OR 0.928, p < 0.001) were all negatively associated with a perfect score. Finally, patient sex and race did not influence the likelihood of a perfect or low survey score.CONCLUSIONSParticipation in HCAHPS surveys was correlated with preoperative and postoperative factors. Among these, procedure approach and type, length of stay, and complications seemed to influence participation the most. No factors were associated with an increased likelihood of receiving a perfect score. Similarly, length of stay and time elapsed since surgery to survey completion were significant negative predictors of receiving perfect HCAHPS survey scores. Increasing comorbid burden was also found to be a negative predictor for high scores. Further study on predictors of inpatient satisfaction within spine surgery is needed.