Time Seeing a Hand Surgeon Is Not Associated With Patient Satisfaction

What Patients Say About Their Orthopaedic Hand and Wrist Surgeons: A Qualitative Analysis of Negative Reviews on Yelp

Background  Patients often turn to online reviews as a source of information to inform their decisions regarding care. Existing literature has analyzed factors associated with positive online patient ratings among hand and wrist surgeons. However, there is limited in-depth analysis of factors associated with low patient satisfaction for hand and wrist surgeons. The focus of this study is to examine and characterize extremely negative reviews of hand and wrist surgeons on Yelp.com. Methods  A search was performed using the keywords "hand surgery" on Yelp.com for eight major metropolitan areas including Washington DC, Dallas, New York, Phoenix, Los Angeles, San Francisco, Boston, and Seattle. Only single-star reviews (out of a possible 5 stars) of hand and wrist surgeons were included. The complaints in the 1-star reviews were then categorized into clinical and nonclinical categories. Result  A total of 233 single-star reviews were included for analysis, which resulted in 468 total complaints. Of these complaints, 81 (18.8%) were clinically related and 351 (81.3%) were nonclinical in nature. The most common clinical complaints were for complication (24 complaints, 6%), misdiagnosis (16 complaints, 4%), unclear treatment plan (16 complaints, 4%), and uncontrolled pain (15 complaints, 3%). The most common nonclinical complaints were for physician bedside manner (93 complaints, 22%), financially related (80 complaints, 19%), unprofessional nonclinical staff (61 complaints, 14%), and wait time (46 complaints, 11%). The difference in the number of complaints for surgical and nonsurgical patients was statistically significant ( p  < 0.05) for complication and uncontrolled pain. Clinical Relevance  Patient satisfaction is dependent on a multitude of clinical and nonclinical factors. An awareness of online physician ratings is essential for hand and wrist surgeons to maintain and improve patient care and patient satisfaction. We believe the results of our study could be used to further improve the quality of care provided by hand and wrist surgeons.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND

Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care.

QUESTIONS/PURPOSES

Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities?

METHODS

This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses.

RESULTS

After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01).

CONCLUSION

Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience.

CLINICAL RELEVANCE

Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Patient-Derived Framework for Quality in Hand Surgery: A Qualitative Analysis

PURPOSE

Despite the growing attention to evaluating care from the patient perspective, the most common definitions and measurements of quality are currently defined by physicians and health systems. Studies have demonstrated how a lack of patient input can lead to discrepancies between patients' and physicians' assessments of quality and, subsequently, worse patient outcomes. Although quality measures are increasingly used in hand surgery, insufficient work has examined whether these quality measures align with what matters to patients. We completed a qualitative study to assess how patients define high-quality care through the pre-, peri-, and postoperative phases of care in hand surgery.

METHODS

Based on our prior work, we created an open-ended interview guide and conducted semistructured interviews with 43 hand surgery patients at 5 tertiary-care institutions during various phases of care. We completed a thematic analysis to generate subcodes and open codes, to identify themes in high-quality care from the patient perspective.

RESULTS

Patients defined high-quality care as a process of (1) setting and meeting clear expectations; (2) achieving functional goals after surgery; and (3) feeling comfortable with and cared for by the care team. We identified the following 4 patient-centered themes that contributed to high-quality care: (1) communication between the patient and care team through all phases of care; (2) efficient and accurate diagnosis and treatment; (3) satisfactory treatment outcomes and postsurgical experience; and (4) acceptable systemic aspects of care.

CONCLUSIONS

Efforts to improve health care delivery should include areas of care that are important to patients. Our results suggest that measuring aspects of care that often go without assessments, such as communication, can maximize care quality as defined by patients.

CLINICAL RELEVANCE

The themes identified in this study can inform efforts towards patient-centered quality measure development.

Virtual Scribe Services Decrease Documentation Burden Without Affecting Patient Satisfaction: A Randomized Controlled Trial

BACKGROUND

Virtual scribe services (VSS) are a contemporary take on the in-person scribes utilized as a means to reduce administrative burden on physicians and enhance the physician-patient interaction. The purpose of this study was to determine whether VSS use could decrease the time an orthopaedic foot and ankle surgeon spends on documentation without diminishing the patient experience as compared with traditional postencounter dictation (TD).

METHODS

Fifty patients presenting for first-time visits with a single orthopaedic foot and ankle surgeon were prospectively enrolled and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time spent documenting away from the patient were recorded. A postencounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician.

RESULTS

Of 50 patients enrolled, 25 were randomized to VSS. Time spent documenting away from the patient differed significantly between VSS and TD (1.2 ± 0.7 minutes for VSS vs 5.8 ± 1.7 minutes for TD, P < .001) as did time elapsed between the end of the visit and the start of dictation (0 ± 0 for VSS vs 118.2 ± 72.7 minutes for TD, P < .001). There was a trend toward more time spent with the patient in the VSS group than in the TD group (14.2 ± 5.9 minutes for VSS vs 11.4 ± 5.1 minutes for TD, P = .069). There were no differences between groups in survey responses regarding satisfaction, empathy, understanding, or perception of sufficient time spent with the physician (P > .05 for each).

CONCLUSIONS

VSS use in an orthopaedic foot and ankle practice significantly decreased documentation time and allowed for completion of documentation during patient visits without differences in quality metrics as compared to TD. Orthopaedic surgeons can consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction.

LEVELS OF EVIDENCE

Level II: Randomized controlled trial.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

Mature Adults at the GP: Length of Visit and Patient Satisfaction—Associations with Patient, Doctor, and Facility Characteristics

Background and objectives: The consultation time for more mature adults is often perceived as longer, increasing with the patient’s age and boosting their satisfaction with the visit. However, factors determining patient satisfaction (PS) or the consultation time (CT) in the population aged 50+ are not clearly identified. A cross-sectional design was used to identify factors specific to the facility (e.g., size, staff turnover), doctor (e.g., seniority, workload), and patient (e.g., self-rated health, impairment of activities) that are related to PS and the CT. Our secondary focus was on the relation of PS to the CT along with the role of the patient’s age and gender for both. Materials and Methods: Doctors (n = 178) and their 1708 patients (aged 50–97) from 77 primary care facilities participated in the study. The Patient Satisfaction with Visit Scale score and the CT were the outcome measures. Results: We identified associations with the CT in terms of the facility-related factors (number of GPs, time scheduling); doctors’ workload and health; and patients’ education, time attending GP, and impairments. PS was additionally governed by doctors’ perceived rate of patients aged 65+, as well as the patients’ hospitalization in the prior year, frequency of visits, and impairments. For adults aged 50+ the CT was unrelated to PS and both remained independent of patients’ age. Conclusions: Specific factors in terms of the facility, GP, and patient were identified as related to PS and the CT for participating adults in primary care. During visits of patients aged 50+ at their GP, there is scope for both time-savings and patient satisfaction improvements, when paying attention, e.g., to the time scheduled per visit, the number of doctors employed, and the patients’ impairments.

In Orthopaedic Speciality Care, Longer Explanations Are Not More Caring or More Satisfying

BACKGROUND

Research consistently documents no correlation between the duration of a musculoskeletal specialty care visit and patient experience (perceived empathy of the specialist and satisfaction with care). Based on a combination of clinical experience and other lines of research, we speculate that longer visits are often related to discordance between specialist and patient interpretation of symptoms and weighting of available test and treatment options. If this is true, then the specific duration of time discussing the specialist's interpretations and options with the patient (expertise transfer) might correlate with satisfaction with care and perceived empathy of the clinician even if the total visit time does not.

QUESTIONS/PURPOSES

(1) What demographic or mental health factors are associated with the duration of expertise transfer? (2) What factors, including the duration of expertise transfer, are associated with the patient's satisfaction with the visit and perceived clinician empathy?

METHODS

In a cross-sectional study, 128 new and returning English-speaking adult outpatients seeking care from one of three orthopaedic specialists in two urban practices between September and November 2019 were enrolled and agreed to audio recording of the visit. A total of 92% (118) of patients completed the questionnaire and had a usable recording. Participants completed a sociodemographic survey, the Patient-Reported Outcome Measure Information System Depression computer adaptive test (PROMIS Depression CAT; a measure of symptoms of depression), the Short Health Anxiety Index (SHAI-5; a measure of symptoms of hypochondriasis, a form of symptoms misinterpretation), the Pain Catastrophizing Scale (PCS-4; a measure of misinterpretation of symptoms), an ordinal measure of patient satisfaction (dichotomized into satisfied or not because of strong ceiling effects), and the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE; a measure of perceived clinician empathy). The duration of expertise transfer and the total duration of the visit were measured by two raters with acceptable reliability using software that facilitates segmentation of the visit audio recording. To determine factors associated with the duration of expertise transfer, satisfaction, and empathy, we planned a multivariable analysis controlling for potential confounding variables identified in exploratory bivariable analysis. However, there were insufficient associations to merit multivariable analysis.

RESULTS

A longer duration of expertise transfer had a modest correlation with catastrophic thinking (r = 0.24; p = 0.01). Complete satisfaction with the visit was associated with less health anxiety (6 [interquartile range 5 to 7] for complete satisfaction versus 7 [5 to 7] for less than complete satisfaction; p = 0.02) and catastrophic thinking (4 [1 to 7] versus 5 [3 to 11]; p = 0.02), but not with the duration of expertise transfer. Greater perceived clinician empathy had a slight correlation with less health anxiety (r = -0.19; p = 0.04).

CONCLUSION

Patients with greater misinterpretation of symptoms experience a slightly less satisfying visit and less empathetic relationship with a musculoskeletal specialist despite a longer duration of expertise transfer. This supports the concept that directive strategies (such as teaching healthy interpretation of symptoms) may be less effective then guiding strategies (such as nurturing openness to alternative, healthier interpretation of symptoms using motivational interviewing tactics, often over more than one visit or point of contact).

LEVEL OF EVIDENCE

Level II, therapeutic study.

The use of online video consultations in the aftercare of orthopedic patients: a prospective case-control study

Background

Video consultations have proven to be an efficient source of support for patient-doctor interactions and have become increasingly used in orthopedics, especially during the COVID-19 pandemic. This study analyzed both patients’ and doctors’ acceptance of an orthopedic telemedical consultation (OTC) and compared the results of OTC examinations to the results of live consultation (LC) to identify discrepancies.

Methods

The study was carried out in an orthopedic department of a German hospital between 2019 and 2020. After written informed consent was obtained, patients voluntarily presented for follow-up by OTC and LC. The experience with and attitudes toward OTC among both patients and doctors was evaluated (using Likert scale-scored and open questions, 26 to 28 items). The results of the OTC and LC examinations were compared using a 12-item checklist. The data were analyzed by quantitative and qualitative statistics.

Results

A total of 53 patients were included, each of whom completed an OTC and an LC. The OTC was rated as pleasant, and the experience was rated as very satisfying (average rating on a 5-point Likert scale, with 1 indicating strong agreement: doctors: 1.2; patients: 1.3). Various technical and organizational challenges were identified. Compared to LC, OTC showed no significant differences in patient history or in inspection, palpation, or active range of motion results. Only for the functional or passive joint assessment did LC show significantly higher suitability (p < 0.05) than OTC. Recommendations for further procedures did not differ significantly between OTC and LC.

Conclusions

Because of the high acceptance and the objective benefits of OTC and the similarity of clinical results with LC, OTC is recommendable for orthopedic follow-up examinations. To better assess joint functionality, meaningful digital alternatives for established examination methods should be further investigated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04653-3.

Determinants of caregiver satisfaction in pediatric orthopedics

This study investigates determinants of pediatric orthopedic surgery patients' parent or guardian (caregiver) satisfaction with the physician in an outpatient office setting. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients that checked into the pediatric orthopedic clinic at the authors' institution from 1 March 2017 to 1 November 2018. Questionnaires given in clinic include the Newest Vital Sign and The Literacy in Musculoskeletal Problems survey to measure general and musculoskeletal health literacy, respectively, demographic information, expected/estimated wait time, Consultation and Relational Empathy Measure, and Consumer Assessment of Healthcare Providers and Systems Clinician and Group. After multivariate regression, only perceived physician empathy as measured by the Consultation and Relational Empathy Measure score was significantly correlated with caregiver satisfaction (P < 0.0001), accounting for 56% of the variability of caregiver satisfaction scores. The odds of a satisfaction score of at least 9 out of 10 were 21% higher for every unit increase of the Consultation and Relational Empathy Measure score [odds ratio = 1.21 (P < 0.0001)]. After logistic regression, the caregiver's gender was also correlated with patient satisfaction and the odds of a patient satisfaction score ≥9 for males was less than 1/4th that of females [odds ratio = 0.16 (P = 0.040)]. The most important determinant of caregiver satisfaction with the physician in an outpatient pediatric orthopedic setting is perceived physician empathy. This accounts for the majority of the caregiver's satisfaction. This is the first study to determine this relationship in pediatric orthopedic surgery.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND

Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry.

QUESTIONS/PURPOSES

In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry?

METHODS

In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables.

RESULTS

The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry.

CONCLUSION

A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being.

LEVEL OF EVIDENCE

Level III, therapeutic study.

What Are the Priming and Ceiling Effects of One Experience Measure on Another?

Patient-reported experience measures have notable ceiling effects which can hinder efforts to learn and improve. This study tested whether an iterative (Guttman-style) satisfaction questionnaire combined with instructions intended to give people agency to critique us primes responses on an ordinal scale and reduces ceiling effects. Among the 161 subjects randomly assigned to complete an iterative satisfaction questionnaire before or after an ordinal scale, there was no difference in mean satisfaction (no priming). The Guttman scale was more normally distributed and had slightly less ceiling effect when compared to the ordinal scale. Iterative satisfaction scales partially mitigate ceiling effects. The absence of priming suggests that attempts to encourage agency and reflection have limited ability to reduce ceiling effects, and alternative approaches should be tested.

Impact of Consultation Length on Satisfaction in Patients with Chronic Low Back Pain: A Nationwide Multicenter Study in Japan

Introduction

Chronic low back pain (CLBP) is a major health burden worldwide and requires patient satisfaction with treatment. Consultation length can be an important factor in patient satisfaction, but few studies have investigated the impact of consultation length on satisfaction in patients with CLBP. This study tried to elucidate the impact of consultation length on clinical outcomes in patients with CLBP.

Methods

This study is part of an analysis using the database of the nationwide, multicenter cohort for CLBP performed by the Project Committee of the Japanese Society for Spine Surgery and Related Research. A total of 427 patients aged 20-85 years (median age, 73.0 years; female, 58.6%) with CLBP were prospectively followed-up monthly for 6 months. Multivariable nonlinear regression analyses were performed to assess the effect of consultation length on outcome measures including subjective satisfaction score, EuroQol 5-dimension, Japanese Orthopaedic Association (JOA) score, Roland-Morris Disability Questionnaire, JOA Back Pain Evaluation Questionnaire, visual analog scale (VAS) and Medical Outcome Survey short-form 8-item health survey that evaluated at the next phase. Furthermore, we assessed whether the effect of consultation length on patient satisfaction was modified by the baseline Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) score for patient and physician versions.

Results

VAS for CLBP was the only score that correlated significantly with consultation length (P = 0.018). Satisfaction score showed a significant positive correlation with consultation length in patients with the highest baseline BS-POP scores (P < 0.2). Moreover, consultation lengths more than 7.6 min and 15.1 min offered increase of satisfaction if patients show the highest BS-POP scores on patient and physician versions, respectively.

Conclusions

These findings suggest that a sufficiently long consultation is an important factor for subjective satisfaction in the patients with CLBP, particularly in patients with psychological problems.

Factors Associated With Patient Satisfaction Measured Using a Guttman-Type Scale

Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (β: -0.03; 95% CI: -0.05 to -0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters' degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of -0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.

Attempts to Limit Censoring in Measures of Patient Satisfaction

Background:

Measures of patient satisfaction are increasingly used to measure patient experience. Most satisfaction measures have notable ceiling effects, which limits our ability to learn from variation among relatively satisfied patients. This study tested a variety of single-question satisfaction measures for their mean overall score, ceiling and floor effect, and data distribution. In addition, we assessed the correlation between satisfaction and psychological factors and assessed how the various methods for measuring satisfaction affected net promoter scores (NPSs).

Methodology:

A total of 212 patients visiting orthopedic offices were enrolled in this randomized controlled trial. Patients were randomized to 1 of 5 newly designed, single-question satisfaction scales: (a) a helpfulness 11-point ordinal scale from 0 to 10, (b) a helpfulness ordinal 11-point scale from 0 to 5 (ie, with 1.5, 2.5, etc), (c) a helpfulness 100-point slider, (d) a satisfaction 11-point ordinal scale from 0 to 10, and (e) a willingness to recommend 11-point ordinal scale from 0 to 10. Additionally, patients completed the 2-item Pain Self-Efficacy Questionnaire (PSEQ-2), 5-item Short Health Anxiety Inventory (SHAI-5) Scale, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression. We assessed mean and median score, ceiling and floor effect, and skewness and kurtosis for each scale. Spearman’s correlation tests were used to test correlations between satisfaction and psychological status. Finally, we assessed the NPS for the various scales.

Results:

Ceiling effects ranged from 29% to 68%. The 11-point ordinal helpfulness scale from 0 to 10 had the least ceiling effect (29%). All of the scales were asymmetrically distributed, with the 11-point ordinal scale from 0 to 5 having the most Gaussian distribution (skew = 0.64 and kurtosis = 2.3). Satisfaction scores did not correlate with psychological factors: PSEQ-2 (r = 0.04; P = .57), SHAI-5 (r = 0.01; P = .93), and PROMIS Depression (r = −0.04; P = .61). Net promoter scores varied substantially by scale design, with higher scores corresponding with greater ceiling effects.

Conclusions:

Variations in scale types, text anchors, and lead-in statements do not eliminate the ceiling effect of single-question measures of satisfaction with a visit to an orthopedic specialist. Further studies might test other scale designs and labels.

Level of Evidence:

Diagnostic; Level II

The Communicative Ecology of Chinese Patients' Experiences with Health Care

Patient satisfaction and trust are important intermediate outcomes along pathways linking clinician-patient communication to improve well-being, but they are difficult to achieve in Chinese health care. Problematic physician-patient interactions, questionable health-care organizational practices, and media coverage of medical scandals may have contributed to this problem. Nevertheless, there isscant literature documenting reasons underlying dissatisfaction with Chinese health care. Using Street's ecological model of communication in medical encounters as a conceptual framework, this study explores how media and organizational factors affect Chinese patients' satisfaction and trust both directly and as mediated by the quality of patients' past communication experiences with clinicians. A survey was conducted among 257 Ob-gyn patients in a top-tier hospital in Sichuan, China. The results show that several organizational and media factors, along with patients' experiences with physician communication, predict patient satisfaction and trust. Perceptions of physician communication mediated some of the relationships between organizational and media factors with outcomes. Theoretical and practical implications are discussed, particularly with respect to improving health-care services in China.

Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices

BACKGROUND

Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience.

OBJECTIVE

To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings.

DESIGN

Retrospective cohort.

PARTICIPANTS

A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017.

MAIN MEASURES

We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day.

RESULTS

We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break.

CONCLUSIONS

In primary care, appointment time of day is associated with patient-reported experience.

Do Patient Sociodemographic Factors Impact the PROMIS Scores Meeting the Patient-Acceptable Symptom State at the Initial Point of Care in Orthopaedic Foot and Ankle Patients?

BACKGROUND

Patient-reported outcome measures such as the Patient-Reported Outcomes Measurement Information System (PROMIS) allow surgeons to evaluate the most important outcomes to patients, including function, pain, and mental well-being. However, PROMIS does not provide surgeons with insight into whether patients are able to successfully cope with their level of physical and/or mental health limitations in day-to-day life; such understanding can be garnered using the Patient-acceptable Symptom State (PASS). It remains unclear whether or not the PASS status for a given patient and his or her health, as evaluated by PROMIS scores, differs based on sociodemographic factors; if it does, that could have important implications regarding interpretation of outcomes and fair delivery of care.

QUESTIONS/PURPOSES

In a tertiary-care foot and ankle practice, (1) Is the PASS associated with sociodemographic factors (age, gender, race, ethnicity, and income)? (2) Do PROMIS Physical Function (PF), Pain Interference (PI), and Depression scores differ based on income level? (3) Do PROMIS PF, PI, and Depression thresholds for the PASS differ based on income level?

METHODS

In this retrospective analysis of longitudinally obtained data, all patients with foot and ankle conditions who had new-patient visits (n = 2860) between February 2015 and December 2017 at a single tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression survey and answer the following single, validated, yes/no PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your functional impairment, do you consider that the current state of your foot and ankle is satisfactory?" Of the 2860 new foot and ankle patient visits, 21 patient visits (0.4%) were removed initially because all four outcome measures were not completed. An additional 225 patient visits (8%) were removed because the patient chart did not contain enough information to accurately geocode them; 15 patients visits (0.5%) were removed because the census block group median income data were not available. Lastly, two patient visits (0.1%) were removed because they were duplicates. This left a total of 2597 of 2860 possible patients (91%) in our study sample who had completed all three PROMIS domains and answered the PASS question. Patient sociodemographic factors such as age, gender, race, and ethnicity were recorded. Using census block groups as part of a geocoding method, the income bracket for each patient was recorded. A chi-square analysis was used to determine whether sociodemographic factors were associated with different PASS rates, two-way ANOVA analyses with pairwise comparisons were used to determine if PROMIS scores differed by income bracket, and a receiver operating characteristic (ROC) curve analysis was performed to determine PASS thresholds for the PROMIS score by income bracket. The minimum clinically important difference (MCID) for PROMIS PF in the literature in foot and ankle patients ranges from about 7.9 to 13.2 using anchor-based approaches and 4.5 to 4.7 using the ½ SD, distribution-based method. The MCID for PROMIS PI in the literature in foot and ankle patients ranges from about 5.5 to 12.4 using anchor-based approaches and about 4.1 to 4.3 using the ½ SD, distribution-based method. Both were considered when evaluating our findings. Such MCID cutoffs for PROMIS Depression are not as well established in the foot and ankle literature. Significance was set a priori at p < 0.05.

RESULTS

The only sociodemographic factor associated with differences in the proportion of patients achieving PASS was age (15% [312 of 2036] of patients aged 18-64 years versus 11% [60 of 561] of patients aged ≥ 65 years; p = 0.006). PROMIS PF (45 ± 10 for the ≥ USD 100,000 bracket versus 40 ± 10 for the ≤ USD 24,999 bracket, mean difference 5 [95% CI 3 to 7]; p < 0.001), PI (57 ± 8 for ≥ USD 100,000 versus 63 ± 7 for ≤ USD 24,999, mean difference -6 [95% CI -7 to -4]; p < 0.001), and Depression (46 ± 8 for the ≥ USD 100,000 bracket versus 51 ± 11 for ≤ USD 24,999, mean difference -5 [95% CI -7 to -3]; p < 0.001) scores were better for patients in the highest income bracket compared with those in the lowest income bracket. For PROMIS PF, the difference falls within the score change range deemed clinically important when using a ½ SD, distribution-based approach but not when using an anchor-based approach; however, the score difference for PROMIS PI falls within the score change range deemed clinically important for both approaches. The PASS threshold of the PROMIS PF for the highest income bracket was near the mean for the US population (49), while the PASS threshold of the PROMIS PF for the lowest income bracket was more than one SD below the US population mean (39). Similarly, the PASS threshold of the PROMIS PI differed by 6 points when the lowest and highest income brackets were compared. PROMIS Depression was unable to discriminate the PASS.

CONCLUSIONS

Discussions about functional and pain goals may need to be a greater focus of clinic encounters in the elderly population to ensure that patients understand the risks and benefits of given treatment options at their advanced age. Further, when using PASS in clinical encounters to evaluate patient satisfaction and the ability to cope at different symptom and functionality levels, surgeons should consider income status and its relationship to PASS. This knowledge may help surgeons approach patients with a better idea of patient expectations and which level of symptoms and functionality is satisfactory; this information can assist in ensuring that each patient's health goal is included in shared decision-making discussions. A better understanding of why patients with different income levels are satisfied and able to cope at different symptom and functionality levels is warranted and may best be accomplished using an epidemiologic survey approach.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Patient Satisfaction in the Preoperative Period: Preparing for Hand Surgery

Background: The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Methods: Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Results: Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, P = 0.005) and 5 or more total encounters (80%, P = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon (P = 0.267) or medical office encounters (P = 0.087), or a patient's perceived health status (P = 0.14). Conclusions: Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.

Wait Times in Musculoskeletal Patients: What Contributes to Patient Satisfaction

Introduction:

The purpose of this study was to determine how wait time duration is associated with patient satisfaction and how appointment characteristics relate to wait time duration and patient satisfaction in the orthopedic surgery clinic.

Methods:

Two hundred sixty-four patients visiting one of 3 ambulatory orthopedic surgery clinics were asked to estimate their wait time and to rate their satisfaction with the visit. The associations between appointment characteristics, wait time, and satisfaction were analyzed using t tests, 1-way analysis of variance, and Pearson correlation coefficients.

Results:

Wait times were significantly different based on visit type, appointment time, whether an X-ray was required, and whether a trainee was involved (P < .001). Patients with wait times less than 30 minutes had higher satisfaction scores (P < .001). Satisfaction ratings were significantly different based on the surgeon’s management recommendation (P = .0211), but were not significantly different based on sex, age, office location, visit type, appointment time subsection, or time spent with the physician (P > .05).

Conclusion:

Wait times negatively correlated with satisfaction. New patient visits, appointment times in the later third of the day, appointments requiring an X-ray, and appointments involving a trainee had significantly longer wait times. Care should be taken to inform patients with visits involving these characteristics that they may experience longer than average wait times.

The psychology of the wait time experience - what clinics can do to manage the waiting experience for patients: a longitudinal, qualitative study

BACKGROUND

Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones.

METHODS

We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6-12 months. We analyzed the interviews using directed and conventional content analysis.

RESULTS

Our study showed that patients' "willingness to wait" is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait.

CONCLUSIONS

Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Satisfaction With Specific and Nonspecific Diagnoses

PURPOSE

Nonspecific upper extremity illnesses (eg,. wrist pain, forearm pain)-where no objectively verifiable pathology is detectable-are common and usually self-limiting. For some patients, a nonspecific diagnosis can contribute to mistrust and disappointment.

METHODS

This study tested the primary null hypothesis that there is no difference in mean overall satisfaction between patients given a specific compared with a nonspecific diagnosis. Second, we assessed factors associated with satisfaction and with nonspecific upper extremity diagnosis.

RESULTS

There was no significant difference between mean satisfaction with nonspecific and specific diagnoses in bivariate analysis. However, when treated as a categorical variable, 22% of the patients with a nonspecific diagnosis had a satisfaction score of 8 or lower compared with 11% of the patients given a specific diagnosis. First visit and greater pain intensity were significantly associated with a nonspecific diagnosis in bivariate analysis. In the multivariable models, no factors were independently associated with satisfaction or with nonspecific diagnoses.

CONCLUSIONS

Although nonspecific diagnoses can sometimes be frustrating for both physician and patient, in this small study using a satisfaction measure with a strong ceiling effect, they were no less satisfying to patients on average and corresponded with slightly greater pain intensity than specific diagnoses.

CLINICAL RELEVANCE

The degree to which nonspecific diagnoses (perhaps in combination with compassionate care and incremental monitoring) can be part of a satisfying treatment experience merits additional investigation.

The Feasibility and Usability of a Ranking Tool to Elicit Patient Preferences for the Treatment of Trigger Finger

PURPOSE

Shared decision making is an approach where physicians and patients collaborate to make decisions based on patient values. This requires eliciting patients' preferences for each treatment attribute before making decisions; a structured process for preference elicitation does not exist in hand surgery. We tested the feasibility and usability of a ranking tool to elicit patient preferences for the treatment of trigger finger. We hypothesized that the tool would be usable and feasible at the point of care.

METHODS

Thirty patients with a trigger finger without prior treatment were recruited from a hand surgery clinic. A preference elicitation tool was created that presented 3 treatment options (surgical release, injection, and therapy and orthosis) and described attributes of each treatment extracted from literature review (eg, success rate, complications). We presented these attributes to patients using the tool and patients ranked the relative importance (preference) of these attributes to aid in their decision making. The System Usability Scale and tool completion time were used to evaluate usability and feasibility, respectively.

RESULTS

The tool demonstrated excellent usability (System Usability Scale: 88.7). The mean completion time was 3.05 minutes. Five (16.7%) patients chose surgery, 20 (66.7%) chose an injection, and 5 (16.7%) chose therapy and orthosis. Patients ranked treatment success and cost as the most and least important attributes, respectively. Twenty-nine (96.7%) patients were very to extremely satisfied with the tool.

CONCLUSIONS

A preference elicitation tool for patients to rank treatment attributes by relative importance is feasible and usable at the point of care. A structured process for preference elicitation ensures that patients understand the trade-offs between choices and can assist physicians in aligning treatment decisions with patient preferences.

CLINICAL RELEVANCE

A ranking tool is a simple, structured process physicians can use to elicit preferences during shared decision making and highlight trade-offs between treatment options to inform treatment choices.

Visit Duration Does Not Correlate with Perceived Physician Empathy

BACKGROUND

Perceived physician empathy is a strong driver of patient satisfaction. We assessed the influence of wait time, time spent with the surgeon, and surgeon stress level on the way patients rated surgeon empathy.

METHODS

One hundred and fourteen patients visiting 1 of 6 participating surgeons were prospectively enrolled in the study. We recorded patient demographics and assessed the patient rating of perceived physician empathy. Time waiting for the surgeon and time spent with the surgeon were measured with use of ambulatory tracking systems and by research assistants with stopwatches outside the patient rooms. Patient ratings of surgeon empathy were assessed with use of the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE), and surgeon stress level was assessed with use of the Perceived Stress Score short form. The mean wait time was 30 ± 18 minutes, and the mean time spent with the surgeon was 8.7 ± 5.3 minutes. Two separate multilevel linear regression models were used to compare factors associated with the JSPPPE and time spent with the surgeon.

RESULTS

Neither time spent with the surgeon nor wait time was independently associated with perceived physician empathy; being male, having at least a post-college graduate degree, and higher self-reported surgeon stress levels were independently associated with less perceived empathy. More time spent with the surgeon was independently associated with lower self-reported surgeon stress levels; follow-up visits and visits for a traumatic condition were independently associated with less time spent with the surgeon.

CONCLUSIONS

The results of the present study show that improved communication strategies, rather than shorter wait time or increased time spent with the patient, may increase patient satisfaction. This should be a focus of future research.

Cost, Value, and Patient Satisfaction in Carpal Tunnel Surgery

The cost of carpal tunnel release (CTR) surgery can be decreased and patient satisfaction increased by a few relatively simple changes. Although cost estimates vary in the literature, most investigators agree that open CTR costs less than endoscopic CTR, and the clinic procedure room or ambulatory surgery center is cheaper than the ambulatory surgery center, which is less than the hospital. Patient satisfaction can be increased by making office visits more patient-centered and improving the quality of dialogue between the surgeon and patient.

Patient reported outcomes with remote orthopaedic consultations by telemedicine: A randomised controlled trial

Introduction

Decentralised services through outreach clinics or modern technology reduce patient travel time and cost to society. Telemedicine consultation through videoconference is one such modality. Here, we compared patient-reported health outcomes and satisfaction between video-assisted remote and standard face-to-face orthopaedic consultations.

Methods

This randomised controlled trial included two parallel groups: (1) patients receiving video-assisted remote consultation at a regional medical centre (RMC); and (2) patients receiving standard consultation at the orthopaedic outpatient clinic of the University Hospital of North Norway (UNN). This study included patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. After each consultation, patient satisfaction was determined using patient-completed questionnaires containing questions on patient-reported health (three-level European quality of life five-dimension index (EQ-5D-3L)/European quality of life visual analogue scale (EQ-VAS)) and questions from a validated OutPatient Experiences Questionnaire (OPEQ).

Results

This study included 389 patients, of which 199 received remote consultation and 190 received standard consultation (total of 559 consultations). In all, 99% RMC-randomised patients and 99% UNN-randomised patients evaluated the consultation as very satisfactory or satisfactory. Moreover, 86% RMC-randomised patients preferred video-assisted consultation as the next consultation. No difference was observed in patient-reported health after 12 months between the two groups. EQ-5D index scores were 0.77 and 0.75 for RMC- and UNN-randomised patients, respectively ( p = 0.42).

Discussion

We did not observe any difference in patient-reported satisfaction and health (EQ-5D/EQ-VAS) between video-assisted and standard consultations, suggesting that video-assisted remote consultation can be safely offered to some orthopaedic patients. Moreover, a significantly high proportion of patients selected video-assisted remote consultation as their next consultation, thus strengthening the findings of this study. However, economic aspects should be assessed before widely recommending video-assisted consultation.

Association Between Opioid Intake and Disability After Surgical Management of Ankle Fractures

BACKGROUND

Opioid-centric pain management strategies have created an epidemic of prescription opioid abuse. This study assesses whether opioid intake is associated with disability, satisfaction with treatment, and pain at the time of suture removal and at 5 to 8 months after suture removal following open reduction and internal fixation of ankle fractures.

METHODS

We enrolled 102 adult patients in the study at the time of suture removal, 59 of whom were available for follow-up at 5 to 8 months. At the time of suture removal, we recorded opioid use; trauma-related factors; and scores on measures of disability, pain, and treatment satisfaction. Patients who were available for follow-up completed the disability, pain, and treatment satisfaction measures at 5 to 8 months and their opioid use at that time was recorded.

RESULTS

No association was found between opioid intake and disability at the time of suture removal. No association was found between opioid intake and satisfaction with treatment or satisfaction with pain management at the time of suture removal. At 5 to 8 months after suture removal, no variables were associated with opioid intake. The psychologic measures of pain anxiety and catastrophic thinking were the factors most consistently associated with disability, treatment satisfaction, satisfaction with pain management, pain at rest, and pain with activity at both of the time points.

CONCLUSION

Patients with ankle fractures may be able to use fewer opioids than are currently prescribed and experience levels of disability and treatment satisfaction comparable with those of patients who take greater amounts of opioids, independent of injury characteristics.

LEVEL OF EVIDENCE

Prognostic level II.

Concordance of Patient and Physician Perceptions of Care in an Orthopedic Clinic

It is essential to study whether physicians' perceptions align with their patients' views, as understanding patient perception leads to superior satisfaction and health outcomes. Previous studies have established differences in physician-patient perceptions, but no studies have been conducted in orthopedic clinics. The authors' primary goal was to evaluate differences in physician and patient perceptions of an orthopedic clinic visit. Their secondary objective was to determine the influence of visit length, demographics, and depression risk-level on patient satisfaction. The authors surveyed 143 new patients being seen by orthopedic surgeons at a level I trauma center. After their appointment, these patients completed surveys on satisfaction and likelihood of depression. The authors recorded wait times and visit lengths. Simultaneously, the physicians completed a self-evaluative satisfaction survey. Patients' and physicians' answers were compared using a Wilcoxon signed-rank test. Mann-Whitney and Spearman correlation analyses were used to assess factors that impact satisfaction. Physicians and patients showed no significant differences on most questions of the satisfaction survey, except that physicians reported feeling less satisfied with their own explanations (P<.001). Length of visit was positively correlated with patient satisfaction (R=0.276, P=.001), while waiting times had no effect. Patients at risk for depression were less satisfied with physicians' effort to include them in decision-making (P=.044). Age was a predictor of greater satisfaction with explanations (P=.032) and instructions (P=.009) from the physician. Thus, orthopedic clinics may not exhibit the same physician-patient perception patterns as primary care clinics, potentially because of differences in patient populations, conditions, or expectations. [Orthopedics. 2017; 40(4):242-246.].

Patient Satisfaction in an Outpatient Hand Surgery Office: A Comparison of English- and Spanish-Speaking Patients

BACKGROUND

As health care in the United States transitions from a fee-for-service to an outcomes-based environment, patient satisfaction is increasingly incentivized and publicly reported. Despite the continued growth of the Latino population and concomitant rise in the demand for health care, relatively little is known regarding patient satisfaction in Spanish speakers. We sought to compare patient satisfaction with hand surgery office visits between Spanish- and English-speaking patients.

METHODS

Directly after the office visit, 150 patients (75 English speakers and 75 Spanish speakers) completed a sociodemographic survey, an 11-point ordinal rating of pain intensity, and a survey of satisfaction with the encounter using items derived from the CG-CAHPS (Clinician and Group-Consumer Assessment of Healthcare Providers and Systems) survey. Multivariable regression modeling was used to identify factors associated with patient dissatisfaction.

RESULTS

Overall, 79% of Spanish-speaking patients were satisfied with the physician as compared with 91% of English speakers (P = .041). Compared with English-speaking patients, Spanish speakers were less likely to be satisfied with provider listening carefully (91% vs 100%, P = .007) and spending enough time with them (56% vs 93%, P < .001), as well as with waiting times (81% vs 96%, P = .005). There was no difference with regard to provider showing respect, clarity of communication, and explanation of what was done. Younger age and Spanish language were independent predictors of patient dissatisfaction.

CONCLUSIONS

Spanish-speaking patients are less satisfied with the care provided in a hand surgery office. In light of the growing diversity of the US population and the fact that patient satisfaction is increasingly tied to reimbursement, additional research might identify potential areas of improvement from both the surgeon (eg, communication strategies, cultural competence) and patient (eg health literacy, expectations) perspectives.

Patient Satisfaction Is Associated With Time With Provider But Not Clinic Wait Time Among Orthopedic Patients

Clinic wait time is considered an important predictor of patient satisfaction. The goal of this study was to determine whether patient satisfaction among orthopedic patients is associated with clinic wait time and time with the provider. The authors prospectively enrolled 182 patients at their outpatient orthopedic clinic. Clinic wait time was defined as the time between patient check-in and being seen by the surgeon. Time spent with the provider was defined as the total time the patient spent in the examination room with the surgeon. The Consumer Assessment of Healthcare Providers and Systems survey was used to measure patient satisfaction. Factors associated with increased patient satisfaction included patient age and increased time with the surgeon (P=.024 and P=.037, respectively), but not clinic wait time (P=.625). Perceived wait time was subject to a high level of error, and most patients did not accurately report whether they had been waiting longer than 15 minutes to see a provider until they had waited at least 60 minutes (P=.007). If the results of the current study are generalizable, time with the surgeon is associated with patient satisfaction in orthopedic clinics, but wait time is not. Further, the study findings showed that patients in this setting did not have an accurate perception of actual wait time, with many patients underestimating the time they waited to see a provider. Thus, a potential strategy for improving patient satisfaction is to spend more time with each patient, even at the expense of increased wait time. [Orthopedics. 2017; 40(1):43-48.].

Health Literacy and Time Spent With a Hand Surgeon

PURPOSE

To characterize the relationship between health literacy and duration of new hand surgery office visits.

METHODS

Using a stopwatch from outside the room, we measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) for 224 new patients presenting to 1 of 5 orthopedic hand surgeons (D.R.). Directly after the visit, patients were asked to complete the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper Extremity Function, and Depression. The Newest Vital Sign scores were divided into limited (0-3) and adequate (4-6) health literacy. Medical records were reviewed to collect data on diagnosis, visit type, management, and whether patients were first seen by a resident/fellow. Multiple linear regression modeling was used to characterize the association between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics.

RESULTS

The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy (9.4 minutes) than in patients with adequate health literacy (11.3 minutes), and this difference persisted after adjustment for a broad range of patient and visit characteristics. Greater magnitude of disability was associated with longer visits, as were second-opinion appointments, a diagnosis of nonspecific arm pain or compression neuropathy, and appointments in which operative management was chosen. Visits in which a resident/fellow saw the patient first were shorter than visits without resident/fellow assistance.

CONCLUSIONS

The finding that limited health literacy correlated with shorter visits may suggest that patients who may stand to benefit the most from detailed health education and counseling received less.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon

PURPOSE

To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit.

METHODS

Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration.

RESULTS

Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon.

CONCLUSIONS

Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer.

Pain, Functional Scores, and Radiographic Severity of Illness Influence the Perception of Time Spent With the Physician by Patients Presenting for Initial Evaluation of Knee Osteoarthritis

BACKGROUND

Patient satisfaction has become a significant factor in reimbursement schedules for physicians. A matter of debate is whether the patient's perception of time spent with the physician improves patient satisfaction. We sought to determine whether patient-physican time correlates with patient satisfaction and which factors are associated with patient perception of time.

METHODS

A total of 73 patients who presented for an initial evaluation of knee osteoarthritis were evaluated by the same orthopedic surgeon at an outpatient clinic in New Orleans, LA. Each encounter was timed with a stopwatch. After the physician encounter, patients were asked to fill out a questionnaire assessing their perception of time spent with the physician, subjective pain, satisfaction with the visit, and understanding of the diagnosis and treatment plan. Patients were also asked to complete 4 functionality surveys. Radiographs of the patients' knees were taken and quantified using Kellgren-Lawrence and Ahlbäck grading scales.

RESULTS

We noted no relationship between patient satisfaction and patients' perception of time spent with the physician. Patients perceived their time with the physician to be an average of 6.5 minutes more than the actual time. However, patients who reported higher subjective pain scores (>7 on a 10-point scale) misestimated their time with the physician by nearly 96%, while patients with lower subjective pain scores (<7 on a 10-point scale) misestimated their time with the physician by only 54% (P<0.007). We discovered similar findings in patients with worse Kellgren-Lawrence radiographic scores as well as worse Oxford Knee Scores and Knee injury and Osteoarthritis Outcome Scores. The actual time spent was not different among patients.

CONCLUSION

Patients with greater subjective pain and worse functional status and patients with worse radiographic severity of knee osteoarthritis perceived greater time spent with the physician. However, no relationship between these variables and patient satisfaction scores was seen.

Physician Empathy as a Driver of Hand Surgery Patient Satisfaction

PURPOSE

To examine the relationship between patient-rated physician empathy and patient satisfaction after a single new hand surgery office visit.

METHODS

Directly after the office visit, 112 consecutive new patients rated their overall satisfaction with the provider and completed the Consultation and Relational Empathy Measure, the Newest Vital Sign health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper-Extremity Function, and Depression. We also measured the waiting time in the office to see the physician, the duration of the visit, and the time from booking until appointment. Multivariable logistic and linear regression models were used to identify factors independently associated with patient satisfaction.

RESULTS

Patient-rated physician empathy correlated strongly with the degree of overall satisfaction with the provider. After controlling for confounding effects, greater empathy was independently associated with patient satisfaction, and it alone accounted for 65% of the variation in satisfaction scores. Older patient age was also associated with satisfaction. There were no differences between satisfied and dissatisfied patients with regard to waiting time in the office, duration of the appointment, time from booking until appointment, and health literacy.

CONCLUSIONS

Physician empathy was the strongest driver of patient satisfaction in the hand surgery office setting. As patient satisfaction plays a growing role in reimbursement, targeted educational programs to enhance empathic communication skills in hand surgeons merit consideration.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.