Press Ganey Outpatient Medical Practice Survey Scores Do Not Correlate With Patient-Reported Outcomes After Primary Joint Arthroplasty

Preoperative predictors of two-year satisfaction in hand and wrist surgery patients

Purpose

As stakeholders seek to improve patient outcomes while maintaining cost-effectiveness in an increasingly expensive healthcare system, metrics such as patient satisfaction are becoming more important. This present study sought to identify factors associated with and independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Methods

Patients undergoing hand and wrist surgery at an urban outpatient institution were enrolled preoperatively into a surgical registry and assessed two years postoperatively. Patient satisfaction with surgery was measured at two years postoperatively with the Surgical Satisfaction Questionnaire (SSQ-8). Bivariate analysis determined associations between postoperative satisfaction and patient demographics, injury specifiers, medical history, and multiple patient-reported outcomes (PROs). Multivariable analysis determined independent predictors of two-year postoperative satisfaction following hand and wrist surgery.

Results

Better surgical satisfaction was associated with having never smoked, no preoperative opioid use, lack of an accompanying legal claim, lack of a workers compensation claim, no clinical history of depression/anxiety, less comorbidities, and higher preoperative expectations.Various PROs relating to function, pain, activity, and general health at both baseline and two years demonstrated associations with postoperative satisfaction. Multivariable analysis confirmed that never smoking, lack of a legal claim, and better preoperative Brief Michigan Hand Questionnaire scores were independently predictive of better surgical satisfaction two years following hand and wrist surgery.

Conclusion

At two years following hand and wrist surgery, better patient satisfaction was best predicted by never smoking, no related legal claim, and better baseline Brief Michigan Hand Questionnaire scores.

Level of evidence

III.

The Influence of an Unexpected Symbolic Gift on Postoperative Arthroplasty Patients' Press Ganey Scores

INTRODUCTION

Hospitals use Press Ganey surveys to evaluate patient satisfaction. The goal of our study was to evaluate whether surgeon-driven gifting to patients post-operatively affects Press Ganey Survey responses.

METHODS

There were 1,468 patients undergoing arthroplasty at our institution who were randomized to receive a thank you gift, a small bouquet of flowers, and a note from their provider after surgery, or nothing for completing their pre-operative arthroplasty registry questionnaire. Press Ganey surveys were sent to patients who received and did not receive flowers immediately after their hospital stay and after the patients' first post-operative visit. Scores were reported as the mean score and the fraction of responses with a top-box rating. One-sided student t-tests and Fischer Exact tests were used to assess statistical significance.

RESULTS

Hospital Discharge Patients who received flowers had higher Press Ganey survey scores than patients who did not receive flowers. For example, for "Physician's concerns for questions," they had higher scores (mean difference: 3.7 ± 1.6 points, P = 0.012) and a 9% higher top-box rating (P = 0.032). For "Staff attitude towards visitors," they also had higher scores (mean difference: 2.8 ± 1.3 points, P = 0.019) and a 7% higher top-box rating (P = 0.049). First Follow-up Patients who received flowers had a higher top-box rating for "Concern provider showed for questions" and "Amount of time provider spent with you" by 6% (P = 0.046) and 11% (P = 0.009), respectively. They also had higher scores for "Information provider gave about medications" (mean difference: 4.0 ± 1.6 points, P = 0.009) and 11% higher top-box rating (P = 0.006).

DISCUSSION

Press Ganey Surveys were higher in orthopaedic patients who received bouquets of flowers from their arthroplasty surgeons compared to patients who did not. At follow-up, improved Press Ganey scores persisted if the patient received flowers. The gift of flowers generates patient loyalty to their surgeon.

Examining the Relationship Between Value and Patient Satisfaction With Treatment in Total Joint Arthroplasty

Background

A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome.

Results

This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001).

Conclusions

This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Patient-Reported Outcomes and Surgical Quality

Delivering high-quality surgical care requires knowing how best to define and measure quality in surgery. Patient-reported outcomes (PROs) enable surgeons, health care systems, and payers to understand meaningful health outcomes from the patient's perspective and can be measured using patient-reported outcome measures (PROMs). As a result, there is much interest in using PROMs in routine surgical care, to guide quality improvement and to inform reimbursement pay structures. This chapter defines PROs and PROMs, differentiates PROMs from other quality measures such as patient-reported experience measures, describes PROMs in the context of routine clinical care, and provides an overview of interpreting PROM data. This chapter also describes how PROMs may be applied to quality improvement and value-based reimbursement in surgery.

Are Patient Satisfaction Instruments Harming Both Patients and Physicians?

In this Viewpoint, Richman and Schulman argue that patient satisfaction surveys may not actually reflect clinical performance or assist efforts to improve patient experience and are not useful tools to measure physician performance.

Correlation of Press Ganey Scores With Early Patient Satisfaction After Anterior Cruciate Ligament Reconstruction

Background:

Patient satisfaction metrics are commonly used to assess the quality of health care and affect reimbursement. The Press Ganey Ambulatory Surgery (PGAS) is a satisfaction survey that has emerged as a prominent quality assessment tool; however, no data exist on whether PGAS scores correlate with early postsurgical satisfaction during the PGAS survey administration period in patients who underwent anterior cruciate ligament reconstruction (ACLR).

Purpose:

To determine if PGAS scores correlate with measures of satisfaction and patient-reported outcomes (PROs) at 2 weeks postoperatively in ACLR patients.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

A retrospective review of patients who underwent ACLR at a single institution was performed. Patients who completed the PGAS survey and PROs at 2 weeks postoperatively were included in the study. Surgical satisfaction was measured with the Surgical Satisfaction Questionnaire (SSQ-8), and PROs included 6 Patient-Reported Outcomes Measurement Information System domains. Bivariate analysis between PGAS and PRO scores was conducted using the Spearman rank correlation coefficient (r_S).

Results:

Of the 716 patients who received the PGAS survey after ACLR, 81 patients completed the survey, and 39 patients also completed PROs and were included in the study. Total converted (mean scaled score) and “top box” (percentages of questions with highest rating selected) PGAS scores showed no significant correlations with the SSQ-8 (r_S =–0.24; P = .14). There were no significant correlations between SSQ-8 and PGAS domain scores except for a negative correlation with Facility domain top box scores (r_S =–0.33; P = .04), meaning that patients with higher surgical satisfaction had lower PGAS Facility scores. Total PGAS (converted and top box scores) and PGAS domain scores showed no significant correlation with any of the other PROs.

Conclusion:

PGAS scores showed no significant positive correlation with surgical satisfaction, function, pain, mental health, activity, or expectations of surgery in patients 2 weeks after ACLR. This suggests little to no relationship between PGAS score and surgical satisfaction in the early recovery period after ACLR.

"They looked at me as a person, not just a diagnosis": A qualitative study of patient and parent satisfaction with a specialized primary care clinic for autistic adults

Background

Autistic adults have complex physical and mental healthcare needs that necessitate specialized approaches to healthcare. One promising approach is to embed providers with specialized training or specialty clinics for autistic adults within general primary care facilities. We previously found that autistic adults who received their healthcare through one specialty clinic designed with and for autistic adults had better continuity of care and more preventive service utilization than national samples of autistic adults.

Objective

To characterize factors that increased or decreased satisfaction with healthcare received through a specialty clinic for autistic adults.

Methods

We conducted 30-60-minute semi-structured interviews with autistic adults (N=9) and parents of autistic adults (N=12). We conducted an inductive thematic analysis, using a phenomenological approach.

Results

Factors that increased participants' satisfaction included: (1) receiving personalized care from the provider; (2) spending quality time with the provider; and (3) having strong, positive patient-provider relationships. Factors that decreased participants' satisfaction included: (1) lack of access to services due to scarcity of trained providers; (2) difficulty at times communicating with the provider; and (3) system-level barriers such as policies, practices, or procedures.

Conclusion

Our findings highlight the importance of providers using personalized approaches to care that meet patients' sensory and communication needs and spending quality time with patients to establish strong, positive patient-provider relationships. Our findings also underscore the critical scarcity of healthcare providers who are trained to deliver care for the growing population of autistic adults.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant.

CONCLUSIONS

PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

Preoperative Factors Associated with Press Ganey Patient Satisfaction Scores after Anterior Cruciate Ligament Reconstruction

Patient satisfaction is increasingly used as a metric to evaluate the quality of healthcare services and to determine hospital and physician compensation. The aim of this study was to identify preoperative factors associated with Press Ganey Ambulatory Surgery (PGAS) satisfaction scores, and to evaluate the effect of each PGAS domain score on the total PGAS score variability in patients undergoing anterior cruciate ligament reconstruction (ACLR). A review of a Press Ganey (PG) database at a single center was performed for patients undergoing ACLR between 2015 and 2019. Ninety-nine patients completed the PGAS survey and 54 also completed preoperative demographic and patient-reported outcome measures (PROMs) for an orthopaedic registry. PGAS scores were calculated and bivariate analysis was performed. Multivariable linear regression determined the effect of each of the six PGAS domains on the total PGAS score variability. In the total cohort of 99 patients, no factors were significantly associated with the total PGAS score or any domain scores. For the 54 patients who also participated in the orthopaedic registry, none of the preoperative PROMs were significantly correlated with total PGAS score. However, having a college degree (89 vs. 95 or 97 points; p = 0.02) and continuous femoral nerve catheter (92 vs. 100 points; p = 0.04) was associated with lower personal issue domain scores, while patients with a greater number of prior surgeries had worse registration domain scores (ρ = -0.27; p = 0.049). For the entire cohort, the registration and facility domains contributed the most variability to the total PGAS score, while the physician domain contributed the least. Few preoperative factors are associated with PGAS scores, and total PGAS scores do not significantly correlate with baseline PROMs. Surgeons may have limited ability to improve their PGAS scores given most of the variability in total scores stems from systemic aspects of the patient experience.

Moderate relationship between function and satisfaction of total hip arthroplasty patients: a cross sectional study

PURPOSE

Patient satisfaction regarding their hip replacement is often assumed to be directly linked to functional outcomes. We led this study to answer 2 questions: (1) what is the level of patient satisfaction, function, and quality of life after primary total hip replacement (THR); and (2) what is the relationship between patient satisfaction and functional and quality of life PROMs after THR?

METHODS

We led a retrospective study using our institutional registry of prospectively and consecutively collected data on patients after primary THR undertaken between 2004 and 2017. We included 6710 patients with a complete 2-year set of follow-up data for Oxford Hip Score (OHS) (for assessing patient's function), EQ-5D (for assessing patient's quality of life) and satisfaction PROM scores.

RESULTS

There was a significant improvement in all OHS and EQ-5D scores from preoperative level, and the mean postoperative satisfaction score was 89/100. We found moderate positive correlations between the patients' outcome satisfaction VAS score and OHS (r = 0.665) and EQ-5D (r = 0.554).

CONCLUSIONS

THR is a successful procedure generating high levels of patient function and satisfaction. Because patients' OHS and EQ-5D scores may be influenced by comorbidities, those scores are of poor predictive value in estimating patient satisfaction, and therefore should not be used as a surrogate to determine the success of the THR procedure.

Predictors of two-year patient satisfaction following elective knee surgery

BACKGROUND

Patient satisfaction metrics are increasingly being utilized as tools to evaluate the quality of healthcare and affect reimbursements. The objectives of this study were to (1) identify factors associated with two-year patient satisfaction after elective knee surgery, (2) compare the Surgical Satisfaction Questionnaire-8 (SSQ-8) and a numeric satisfaction scale (NSS), and (3) determine if two-year patient satisfaction can be predicted based on preoperative factors.

METHODS

A total of 365 patients undergoing elective knee surgery at a single center were administered questionnaires to assess demographics, medical history, and various patient-reported outcomes preoperatively and at two years postoperatively. Patient satisfaction was measured at two years postoperatively with SSQ-8 and NSS. Bivariate and multivariate statistical analyses were performed to identify significant associations and independent predictors of satisfaction.

RESULTS

SSQ-8 and NSS scores were significantly correlated (r_s = 0.68, P < 0.0001). Lower SSQ-8 and NSS scores were associated with black race, higher BMI, more comorbidities, unemployment, smoking, higher ASA score, and greater Met Expectations (P < 0.05). Better scores on patient-based outcome measures and better improvement from baseline were significantly correlated with higher satisfaction on both SSQ-8 and NSS. Multivariable analysis identified greater Met Expectations and higher two-year Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores as independent predictors of greater SSQ-8 scores (adjusted r² = .52). Greater Met Expectations and better two-year PROMIS Social Satisfaction scores were independent predictors of NSS score (adjusted r² = .41). In contrast, when only preoperative variables were considered, the multivariable regression model accounted for only 14% of the variance in SSQ-8 and 6% of the variance in NSS.

CONCLUSION

While there are multiple preoperative factors that are associated with two-year patient satisfaction after knee surgery, those factors contribute relatively little to satisfaction. Meeting expectations and better patient-based outcomes at two years are more important.

Institutional Reductions in Opioid Prescribing Following Hip Arthroscopy Do Not Change Patient Satisfaction Scores

Purpose

To investigate what effect decreased opioid prescribing following hip arthroscopy had on Press-Ganey satisfaction survey scores.

Methods

A retrospective review of prospectively collected data was conducted on patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 2014 and October 2019. Inclusion criteria consisted of complete Press-Ganey survey information, no history of trauma, fracture, connective tissue disease, developmental hip dysplasia, autoimmune disease, or previous hip arthroscopy. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy that occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioids.

Results

A total of 113 patients met inclusion criteria, 88 preprotocol and 25 postprotocol. There were no statistically significant differences between groups with respect to patient demographics or intraoperative pathologies (P > .05). Average opioid prescription dropped from 249.6 ± 152 MME (equivalent to 33.3 tablets of oxycodone 5 mg) preprotocol to 108.6 ± 84.7 MME (equivalent to 14.5 tablets of oxycodone 5 mg) postprotocol; P = .0002. There were no statistically significant differences in Press-Ganey survey scores between pre- and postprotocol groups (P > .05).

Conclusions

A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the Press-Ganey survey.

Level of Evidence

Level III, retrospective comparative study.

Effects of surgeon sociodemographics on patient-reported satisfaction

BACKGROUND

Patient-reported satisfaction scores, including the Press Ganey surveys, are increasingly used as measures for quality healthcare among surgical subspecialties. However, the influence of surgeon sociodemographics is not clear.

METHODS

This cross-sectional study analyzed Press Ganey surveys linked to outpatient surgical visits at a single academic institution from January 2015 to December 2018 as they related to surgeon age, gender, and race. The primary outcome variable was achievement of a top-box score (5/5) on likelihood to recommend surgeon queries. Secondary analysis examined the relationship of likelihood to recommend surgeon to other survey questions, such as those regarding surgeon courtesy, concern, understandability, patient inclusion in medical decision making, and patient confidence in surgeon. χ² tests and generalized estimating equation regression models were run to assess correlation.

RESULTS

In bivariate analysis of 36,840 surveys, non-Hispanic white surgeons were more likely to receive likelihood to recommend surgeon top-box ratings than Asian (P < .001) or underrepresented minority surgeons (P < .001). Additionally, male gender (P < .01) and older surgeon age (P < .001) were associated with higher top-box scores. However, in multivariate generalized estimating equation analysis, the effect of age was no longer significant, but female gender continued to be associated with lower odds of top-box likelihood to recommend surgeon ratings (odds ratio 0.83; 95% confidence interval, 0.70%-0.99%), as did Asian compared with white race (odds ratio 0.78; 95% confidence interval, 0.65%-0.95%). Likelihood to recommend surgeon scores correlated most closely with patients' "confidence" in the surgeon rather than measures of courtesy, concern, understandability, or inclusion in medical decision making.

CONCLUSION

Top-box scores varied by surgeon race and gender in correlation with patients' perceived confidence in the provider. Interpretation of Press Ganey scores should account for potential bias in patient satisfaction surveys based on surgeon demographics.

Balanced, Stemmed, and Augmented Articulating Total Knee Spacer Technique

Explantation and placement of an antibiotic spacer is a well-recognized treatment for periprosthetic infection after total knee replacement. Although static spacers may be occasionally indicated, many patients benefit from an articulating spacer that preserves the function and range of motion. However, many articulating spacer techniques provide an imbalanced cement-on-cement articulating knee that cannot tolerate full weight-bearing or provide adequate stability for daily function. A more durable articulating spacer may be ideal by permitting unrestricted weight-bearing, a functional range of motion, and potentially delayed reimplantation for medically complex patients. We present our evolved and reproducible technique for gap-balanced articulating spacers using cement augments and dowel stems. The result is a stable construct that permits full weight-bearing and a functional range of motion.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

Background

The Patient-Reported Outcomes Measurement Information System^Ⓡ (PROMIS^Ⓡ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

Methods

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

Results

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

Conclusion

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

Registration

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02068-9.

Pain intensity in total hip arthroplasty patients: how communication influences satisfaction

INTRODUCTION

An important global measure of health care quality is patient satisfaction. Patient satisfaction partially determines hospital reimbursement for procedures such as total hip arthroplasty (THA). Press Ganey (PG) survey responses assess patient satisfaction, and impact reimbursement. Current efforts to maximise repayment for THA include reducing postoperative pain. The "Pain Management" survey domain is considered a significant factor in patient ratings, but other studies have highlighted staff communication domains as determinants of satisfaction. Therefore, the purpose of this study is to compare PG survey responses to inpatient pain intensity.

METHODS

We queried the PG database for all patients who underwent a THA between November 2012 and January 2015. This yielded a total of 302 patients. Descriptive statistics were performed to analyse patient-level demographics. A multivariate regression model was constructed utilising pain intensity as the dependent variable.

RESULTS

Patients rating of "Communication with Doctors" (B = -25.534; p < 0.001) and "Communication about Medicines" (B = -31.49; p = < 0.001) domains were representative of patient pain intensity. No other factors demonstrated a significant relationship to pain intensity.

CONCLUSIONS

Patient satisfaction continues to be important in care quality. Surrogate markers, such as the PG survey, can guide institutions looking to improve care. Our study revealed scores for "Communication with Doctors" and "Communication about Medicines" best represented true pain intensity levels for THA recipients during the postoperative period. The "Pain Management" domain did not display a relationship to pain intensity. The current method of measuring patient satisfaction should be reassessed to better represent patient responses and outcomes.

Relationship of Press Ganey Satisfaction and PROMIS Function and Pain in Foot and Ankle Patients

BACKGROUND

Patient satisfaction has garnered interest as a tool to measure health care quality. However, orthopedic studies in total joint arthroplasty, spine, and hand patients have offered conflicting relationships between Press Ganey (PG) satisfaction metrics and patient-reported outcome (PRO) measures. No prior study has assessed the relationship between PG and PROs in foot and ankle patients. Whether satisfaction and outcomes instruments, though, measure similar or differing aspects of the patient experience is unclear. Here, we tested if there was an association between Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes and PG satisfaction scores.

METHODS

PG and PROMIS outcomes data for new patient visits to an orthopedic foot and ankle clinic between 2015 and 2017 were retrospectively analyzed. Patients that completed PG satisfaction surveys were included for study. All patients who completed PG surveys and completed one or both PROMIS physical function (PF) or pain interference (PI) metrics administered by computerized adaptive testing were included. Negative binomial regressions were used to compare PRO scores to PG overall satisfaction and PG satisfaction with care provider, adjusting for patient characteristics. Results were reported as dissatisfaction score ratios, which represented the amount of PG dissatisfaction associated with a 10-point increase in PROMIS PF or PI. Of the 3984 new patient visits, only 441 completed the PG survey (11.3% response rate).

RESULTS

Ceiling effects were seen with PG data: 64% of patients reported perfect satisfaction with care provider and 27% had perfect overall satisfaction. Higher function on the PROMIS PF was weakly associated with increased overall satisfaction (ratio = 0.82, 95% CI: 0.68-0.99, P = .039) and increased satisfaction with care provider (ratio = 0.60, 95% CI: 0.40-0.92, P = .019). However, pain (PROMIS PI) was not associated with overall satisfaction or with satisfaction with care provider.

CONCLUSIONS

Based on our data here, patient satisfaction was weakly related to patient-reported function but not pain interference among this subset of new patients presenting to a foot and ankle clinic. Given our essentially negative findings, further study is needed to determine which aspects of the PG satisfaction and PROMIS scores track similarly. Further, our findings add to the growing literature showcasing limitations of the PG tool, including low response rates and notable ceiling effects. If satisfaction metrics and patient-reported outcomes capture differing aspects of the patient experience, we need to better understand how that influences the measurement of health care quality and value.

LEVEL OF EVIDENCE

Level III, comparative study.

Effect of Patient Body Mass Index, Recommendation for Weight Modification, and Nonmodifiable Factors on Patient Satisfaction

INTRODUCTION

Patient satisfaction serves an increasingly important role in health care. Multiple nonmodifiable patient factors have been found to influence patient satisfaction. To the best of our knowledge, however, no study has investigated the influence of body mass index (BMI) on satisfaction scores. The objective of this study was to evaluate whether BMI and provider recommendation for patient weight modification were associated with patient satisfaction.

METHODS

We reviewed Press Ganey patient satisfaction survey scores from 3,044 clinical encounters in an academic orthopaedic center between November 2010 and May 2017. Multiple patient factors, BMI, and recommendation for weight loss, or requirement of weight loss, before surgery were recorded. Patient satisfaction was operationalized as a binary outcome of completely satisfied or not completely satisfied, and multiple logistic regression was used to estimate the odds of being completely satisfied from the subset of potential predictors.

RESULTS

White patients (odds ratio [OR] = 1.340, 95% confidence interval [CI]: 1.113 to 1.584, P = 0.0007) and Medicare-insured patients (OR = 1.260, 95% CI: 1.044 to 1.521, P = 0.0164) were more likely to be completely satisfied, whereas patients being seen by a provider for the first time were less likely to be completely satisfied (OR = 0.728, 95% CI: 0.626 to 0.847, P < 0.0001). BMI, recommendation for weight loss, and requirement of weight modification before surgery were not found to be associated with patient satisfaction.

DISCUSSION

Neither patient BMI nor provider recommendation for weight loss, or as a requirement for surgery, was associated with patient satisfaction. Race, insurance status, and previous visits with the care provider were identified as nonmodifiable patient factors that influence patient satisfaction.

LEVEL OF EVIDENCE

Level III.

Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons

BACKGROUND

High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness.

MATERIALS AND METHODS

Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016.

RESULTS

Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing".

CONCLUSIONS

Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.

Depression and Non-modifiable Patient Factors Associated with Patient Satisfaction in an Academic Orthopaedic Outpatient Clinic: Is it More Than a Provider Issue?

BACKGROUND

Patient satisfaction surveys play an increasingly important role in United States healthcare policy and serve as a marker of provided physician services. In attempts to improve the patient's clinical experience, focus is often placed on components of the healthcare system such as provider interaction and other experiential factors. Patient factors are often written off as "non-modifiable"; however, by identifying and understanding these risk factors for dissatisfaction, another area for improvement and intervention becomes available.

QUESTIONS/PURPOSES

(1) Do patients in the orthopaedic clinic with a preexisting diagnosis of depression report lower satisfaction scores than those without a preexisting diagnosis of depression? (2) What other non-modifiable patient factors influence patient-reported satisfaction?

METHODS

We reviewed Press Ganey Survey scores, which assess patient experiential satisfaction with a single clinical encounter, from 3044 clinic visits (2527 patients) in adult reconstructive, sports, and general orthopaedic clinics at a single academic medical center between November 2010 and May 2017, during which time approximately 19,000 encounters occurred. Multiple patient factors including patient age, gender, race, health insurance status, number of previous clinic visits with their physician, BMI, and a diagnosis of depression were recorded. Patient satisfaction was operationalized as a binary outcome as satisfied or less satisfied, and a multiple logistic regression analysis was used to estimate the odds of being satisfied.

RESULTS

After adjusting for all other covariates in the model, we found that patients with a diagnosis of depression were less likely to be satisfied than patients without this diagnosis (odds ratio 0.749 [95% confidence interval, 0.600-0.940]; p = 0.01). Medicare-insured patients were more likely to be satisfied than non-Medicare patients (OR 1.257 [95% CI, 1.020-1.549]; p = 0.03), patients in the sports medicine clinic were more likely to be satisfied than those seen in the general orthopaedic clinic (OR 1.397 [95% CI, 1.096-1.775]; p = 0.007), and established patients were more likely to be satisfied than new patients (OR 0.763 [95% CI, 0.646-0.902]; p = 0.002).

CONCLUSIONS

Given the association of depression with lower satisfaction with a single visit at the orthopaedic clinic, providers should screen for depression and address the issue during the outpatient encounter. The impact of such comprehensive care or subsequent treatment of depression on improving patient-reported satisfaction offers areas of future study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach

Objective

To use a mixed methods approach to focus quality improvement efforts to enhance patient experience through human-centered design.

Patients and Methods

A mixed method approach began with returned Press Ganey Medical Practice Surveys from a large, multidisciplinary, outpatient medicine practice from July 1, 2016, through June 30, 2017, using correlation and gap analysis. The second phase deployed human-centered design approaches to process map patient journeys and generate opportunities for care improvement and to generate a theoretical framework for designing optimal care experiences.

Results

Our outpatient medical practices have the greatest ability to improve patient experience scores by focusing on how care teams deliver and educate patients on medications, instructions for follow-up care, and explanations about problems or conditions. By leveraging communication, the expertise of our care team members, and connection between patients and care team members, we can employ a variety of observed opportunities to enhance patient experience. Specific opportunities include leveraging tools in the electronic health record, fostering connection through empathy between patients and members of the care team, and capitalizing on the expertise of nurses on the care team.

Conclusion

A mixed methods approach to the analysis and observation of clinical care and business operations allows for the detection of opportunities with the highest potential impact for improvement when resources are constrained.