Surgical inpatient satisfaction: what are the real drivers?

Evaluating a targeted person-centred pain management intervention programme in lumbar spine surgery - a controlled segment-specific before-and-after interventional design

BACKGROUND

Postoperative pain management in lumbar spine surgery care remains a challenge. The aim of this study was to evaluate the impact of a person-centred postoperative pain management intervention programme on lumbar spine surgery patients on postoperative pain, shared decision-making, and satisfaction with postoperative pain management.

METHODS

The study was performed with a controlled before-and-after interventional design in an orthopaedic unit at a university hospital. Person-centred pain management for patients undergoing spine surgery was developed in co-creation by a multi-professional team and implemented throughout the care pathway. The usual care group (pre-intervention) served as a comparison to the intervention group. Pain intensity, shared decision-making in pain management, and patient satisfaction with results of pain management, served as patient-reported measures, collected using the International Pain Outcomes questionnaire and analysed using descriptive statistics.

RESULTS

The intervention showed no benefit for patients' pain and satisfaction, while shared decision-making in pain management was significant lower in the intervention group than in the conventional group. The per-protocol analysis showed no significant differences between groups.

CONCLUSION

The initial assumption of the study, that the implementation of a co-created structured person-centred care pathway would improve patient-reported outcomes, was not confirmed. The periodically low fidelity to the intervention due to organizational constraints (due to sub-optimal organizational conditions and managerial support) may have affected the results.

The Influence of Patient and Surgeon Characteristics on Press Ganey Provider Ratings in Plastic Surgery

BACKGROUND

Although patient satisfaction ratings are increasingly used as hospital and provider performance metrics, these ratings may be affected by factors extraneous to surgeon performance.

OBJECTIVES

The aim of this study was to assess whether outpatient Press Ganey ratings for plastic surgery providers were tied more to provider or patient characteristics.

METHODS

All Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) responses for plastic surgery providers from 2017 to 2023 from a single institution were analyzed. Ordered logistic regression models were used to identify characteristics associated with provider ratings.

RESULTS

In total, 6442 surveys from 4594 patients representing 29 plastic surgery providers were analyzed. Across the patient cohort, 23.2% (N = 1492) rated plastic surgery providers lower than a 10/10. After adjustment, provider characteristics including provider gender, patient-provider gender concordance, and years in practice were not associated with overall provider ratings (all P > .05). In contrast, patient characteristics were associated with provider ratings. Older patient age (odds ratio [OR], 1.02; P < .001) was associated with higher ratings. Finally, self-reported overall health and mental health were associated with lower provider ratings (both P < .05); specifically, mental health categories lower than "Excellent" were associated with significantly lower provider ratings (overall mental health "Very Good': OR, 0.57; "Good": OR, 0.53; "Fair": OR, 0.59; "Poor": OR, 0.55; all P < .05).

CONCLUSIONS

Press Ganey ratings for plastic surgeons are influenced by patient characteristics, including age and mental health. Because satisfaction ratings are increasingly used as performance metrics in plastic surgery, adjusted rating models may be needed to more accurately reflect surgeon performance.

The Effect of Social Deprivation on Patient Satisfaction in Otolaryngology Clinics

OBJECTIVES

Multiple factors have been associated with lower satisfaction scores. We hypothesize that patients with a more deprived socioeconomic status will have different patient satisfaction scores than patients of higher socioeconomic status.

METHODS

We reviewed Press Ganey satisfaction scores for new, outpatient visits between January 1, 2014, and December 31, 2018. Due to the high ceiling effects of the survey, "satisfaction" was defined as achieving a perfect score of 100. We determined social deprivation using the 2015 Area Deprivation Index (ADI) which serves as a proxy for socioeconomic status derived from zip codes. Patient satisfaction was defined as a binary variable. Univariate and multivariate binary logistic regression analyses were used to identify factors correlated with patient satisfaction.

RESULTS

There were 3239 unique new patients with completed surveys. Univariate analysis demonstrated decreased odds of achieving satisfaction for both the Total Score and Provider Sub-Score for each decile increase in ADI (OR 0.94; CI = 0.908-0.981; P = .003 and OR 0.94; CI = 0.91-0.98; P = .002 respectively). Multivariate analysis revealed the odds for reporting satisfaction for each decile increase in ADI were 0.96 for Total Score (CI = 0.921-0.998; P = .038) and 0.96 for Provider Sub-Score (CI = 0.92-0.993; P = .019). Patients in the most deprived quartile, compared to the least deprived, were significantly less likely to be satisfied with their care for both Total Score (OR 0.70; CI = 0.564-0.865; P = .001) and Provider Sub-Score (OR 0.69; CI = 0.558-0.852; P = .001).

CONCLUSIONS

Increased social deprivation was an independent predictor of lower patient satisfaction in otolaryngology outpatients using the Press Ganey survey. This non-modifiable outcome should be taken into consideration when evaluating patient satisfaction scores and offers further support to the need of addressing and improving healthcare discrepancies in the field of otolaryngology.

LEVEL OF EVIDENCE

Level 3.

Patient satisfaction and associated factors towards surgical service among patients undergoing surgery at referral hospitals in western Amhara Regional State, Ethiopia

Background

Patient satisfaction is a growing concern in all aspects of healthcare. Assessing patient satisfaction has paramount importance for measuring the level of care provided by a health system. The present study aimed to measure the levels of satisfaction among patients undergoing invasive surgery in the referral hospitals of the Western Amhara Regional State.

Methods

A cross-sectional study design was employed. The data were collected from 422 study participants from February 6 to April 6, 2020. The participants were selected using systematic random sampling technique. Interviewer administered questionnaire and chart review were used for data collection. A binary logistic regression model was used to identify the association between independent variables and patient satisfaction. Level of significance was considered at p value less than 0.05 with 95% confidence level.

Result

Of the total participants, 290 (68.7%, 95% CI: 64.5-73.5) were found to be satisfied with surgical service. Factors such as age >58 years [AOR = 3.80, 95% CI (1.53-9.46)], 47-58 years [AOR = 2.47, 95%CI (1.07-5.71)], those with no formal education [AOR = 2.73, 95% CI (1.18-6.32)], primary school education [AOR = 3.89, 95%CI (1.65-9.17)] and secondary school education [AOR = 3.37, 95%CI (1.38-8.23)], no history of previous surgical admission [AOR = 2.09, 95%CI (1.07-4.08)], length of stay in the hospital <7 days [AOR = 2.13,95%CI(1.21-3.75)] and elective admission for surgery [AOR = 1.75, 95%CI (1.03-2.99)] were significantly associated with patient satisfaction towards surgical service.

Conclusion

The proportion of patient satisfaction towards surgical service was found to be low. Factors including age, educational status, history of previous surgical admission, length of stay in the hospital and elective admission for surgery were associated with patient satisfaction. This suggests that healthcare organizations should focus on providing patients with respectful and compassionate patient care approach while paying close attention to how patients are treated.Moreover, in order to provide patient-focused care, health care providers should strengthen their usage of patient characteristics including age, educational level, and type of surgery while developing patient focused care plan.

Novel Way to Improve Satisfaction, Comprehension, and Anxiety in Caregivers: A Randomized Trial Exploring the Use of Comprehensive, Illustrated Children's Books for Pediatric Surgical Populations

BACKGROUND

Surgery generates anxiety and stress, which can negatively impact informed consent and postoperative outcomes. This study assessed whether educational, illustrated children's books improve comprehension, satisfaction, and anxiety of caregivers in pediatric surgical populations.

METHODS

A prospective randomized trial was initiated at a tertiary care children's hospital. All patients ≤ 18 years old with caregiver and diagnosis of 1) uncomplicated appendicitis (English or Spanish speaking); 2) ruptured appendicitis; 3) pyloric stenosis; 4) need for gastrostomy tube; or 5) umbilical hernia were eligible. Conventional consent was obtained followed by completion of 17 validated survey questions addressing apprehension, satisfaction, and comprehension. Randomization (2:1) occurred after consent and before operative intervention with the experimental group (EG) receiving an illustrated comprehensive children's book outlining anatomy, pathophysiology, hospital course, and postoperative care. A second identical survey was completed before discharge. Primary outcomes were caregiver apprehension, satisfaction, and comprehension.

RESULTS

Eighty caregivers were included (55: EG, 25: control group [CG]). There were no significant differences in patient or caregiver demographics between groups. The baseline survey demonstrated no difference in comprehension, satisfaction, or apprehension between groups (all p values NS). After intervention, EG had significant improvement in 14 of 17 questions compared with CG (all p < 0.05). When tabulated by content, there was significant improvement in comprehension (p = 0.0009), satisfaction (p < 0.0001), and apprehension (p < 0.0001).

CONCLUSION

The use of illustrated educational children's books to explain pathophysiology and surgical care is a novel method to improve comprehension, satisfaction, and anxiety of caregivers. This could benefit informed consent, understanding, and postoperative outcomes.

Evaluating Factors That Influence Patient Satisfaction in Otolaryngology Clinics

OBJECTIVES

To identify factors that influence patient satisfaction during outpatient visits in various settings of otolaryngology clinics in an academic medical center.

STUDY DESIGN

Retrospective review.

SETTING

Academic medical center.

METHODS

We reviewed Press Ganey patient satisfaction survey responses for new, outpatient visits between January 1, 2014 and December 31, 2018. Self-reported race was identified using electronic medical records. Multivariate binary logistic regression analyses were used to identify continuous and categorical variables associated with patient satisfaction.

RESULTS

There were 3998 unique new patient visits with completed surveys. Multivariate analysis revealed that responses for patients <18 years old are less likely to be satisfied with their care compared to patients ≥18 years old (OR 0.66; P < .001). For each 10-minute increase in wait time, patients were 43.4% less likely report satisfaction (P < .001). African American patients were also less likely to report satisfaction (OR 0.22; P = .043) while Native Hawaiian and Pacific Islanders were over 3 times more likely to be satisfied (OR 3.6; P = .013). Additionally, Medicare patients and those who were seen at community satellite clinics compared to the main University Hospital had increased odds of achieving satisfactory care (OR 1.3; P = .005 and OR 1.3; P = .002, respectively).

CONCLUSIONS

Wait time, clinic location, patient race, insurance provider, and age were all shown to significantly influence patient-reported satisfaction. Understanding how these variables influence patient satisfaction will hopefully lead to processes that improve patient satisfaction.

LEVEL OF EVIDENCE

Level 3.

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey

ABSTRACT

Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

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

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

The Impact of Social Deprivation on Orthopaedic Outpatient Satisfaction Using the Press Ganey Outpatient Medical Practice Survey

INTRODUCTION

In orthopaedics, multiple factors (patient age, wait time, and depression) have been associated with lower Press Ganey Outpatient Medical Practice Survey (PGOMPS) patient satisfaction scores. We hypothesized that increased social deprivation is an independent predictor of lower patient satisfaction, as measured by the PGOMPS.

METHODS

We retrospectively reviewed unique new outpatient orthopaedic surgery visits between January 1, 2014, and December 31, 2016, at a single tertiary academic institution. Given the high ceiling effects, satisfaction was defined a priori as achieving a score above the 33rd percentile. Social deprivation was determined using the 2015 Area Deprivation Index (ADI). Univariate and multivariable binary logistic regressions were used to detect factors associated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.

RESULTS

Of the 4,881 included patients, the mean age was 53.3 ± 15.9 years, 59.3% were women, and mean ADI was 30.1 ± 19.2. Univariate analysis revealed a significantly decreased odds of achieving satisfaction on the Total Score for each decile increase in ADI (odds ratio [OR] 0.94; P < 0.001). Compared with the least deprived quartile, patients of the most deprived quartile were significantly less likely to report satisfaction for both the Total Score (OR 0.56; P = 0.001) and Provider Sub-Score (OR 0.63; P = 0.011). Multivariable analysis revealed that the odds of achieving satisfaction for each decile increase in ADI were 0.96 for the Total Score (P = 0.014) and 0.95 for the Provider Sub-Score (P = 0.004), independent of age, wait time, race, subspecialty, provider type, and the clinic setting.

CONCLUSIONS

Increased social deprivation was an independent predictor of orthopaedic outpatient dissatisfaction on the PGOMPS. These findings should be considered when interpreting patient satisfaction scores and lend further support in an effort to improve healthcare inequalities.

LEVEL OF EVIDENCE

Level III.

It's not you, It's me: The influence of patient and surgeon gender on patient satisfaction scores

BACKGROUND

Surgeons face the unique challenge of being responsible for both clinical encounters and surgical outcomes. We aim to explore how patient evaluations of surgeons may be influenced by patient and provider factors.

METHODS

Patient responses from the 2016 CGCAHPS survey at a single institution were identified. A Poisson regression model was used to identify patient/provider factors associated with ratings.

RESULTS

11,007 surveys of 134 surgeons were included. After adjustment, higher overall surgeon ratings were associated with older patient age (p < 0.001) and male patient gender (p = 0.001). Lower ratings were associated with higher patient education (p < 0.001) and lower patient self-health ratings (p < 0.001). Although female surgeons tended to have higher communication scores, overall scores did not differ based on any surgeon factors.

CONCLUSIONS

Patient satisfaction scores of surgeons are more closely correlated with patient variables than surgeon factors. This may have implications for physician performance evaluation in value-based care models.

Immediate and Long-Term Health Care Support Needs of Older Adults Undergoing Cancer Surgery: A Population-Based Analysis of Postoperative Homecare Utilization

BACKGROUND

Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA.

METHODS

This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used.

RESULTS

Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%).

CONCLUSION

Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.

Evaluating opportunities for improved orthopedics outpatient satisfaction: an analysis of Press Ganey® Outpatient Medical Practice Survey responses

INTRODUCTION

The Press Ganey® Outpatient Medical Practice Survey (PGOMPS) is composed of 10 provider-specific and 15 non-provider-specific questions. Some healthcare systems link PGOMS overall scores to physician reimbursements. The aim of this study was to determine the frequency of patient satisfaction across individual PGOMPS question, the null hypothesis being that there was no variability between the frequency of satisfaction and similar questions.

METHODS

We reviewed all new patient orthopedic PGOMPS scores between January 2014 and December 2017. Due to the large ceiling effect, satisfaction was defined as a perfect total score. The frequency of perfect scores for each question was calculated.

RESULTS

Five thousand one hundred sixty-three patients met the inclusion criteria. Two thousand two hundred sixty-six (43.89%) provider-specific questions received perfect satisfaction versus 986 (19.10%) with perfect satisfaction for non-provider-specific questions (p <  0.001). The five questions most likely to receive perfect satisfaction were MD friendliness/courtesy (80.36), MD spoke using clear language (80.35%), likelihood to recommend practice (79.11%), likelihood to recommend MD (78.8%), and MD confidence (78.74%). The five least likely were convenience of office hours (60.44%), ease of getting on phone (59.72%), ability to get desired appointment (59.50%), wait time (54.63%), and information about delays (53.80%).

CONCLUSIONS

Our results suggest that the majority of orthopedic patients are satisfied with their provider, demonstrating that room for improvement is limited with provider-specific areas. Leaders of health care teams should consider these results when seeking to improve patient satisfaction scores and determining how and if scores should be linked to reimbursements.

Primer on adult patient satisfaction in perioperative settings

The topic of patient satisfaction has gained increasing importance over the past decade. Due to the impact of patient satisfaction on health care quality, understanding factors that predict satisfaction is vital. The purpose of this review is to examine the literature and identify factors related to patient perioperative satisfaction as well as predictive variables that, if modified, can enhance satisfaction scores of patients undergoing surgery. Our review reports that patient satisfaction scores are affected by modifiable factors such as clinician-patient communication, information provision to patients, and operational function of a hospital. Non-modifiable factors affecting patient satisfaction scores include patient demographics such as gender, age, and education. In order to enhance patient perioperative satisfaction, we suggest that anesthesiologists and surgeons focus their efforts on enhancing their communication skills and providing information that is appropriately tailored to the understanding of their patients.

Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database

BACKGROUND

Alloplastic breast reconstruction is safe in well-selected older women. The impact of timing of surgery on complication rates is unknown. This study aimed to determine the immediate (30-day) postoperative complication rates of older women who underwent immediate (IBR) and delayed breast reconstruction (DBR) with alloplastic techniques.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify women ≥70 years old with in situ or invasive breast cancer who underwent either IBR or DBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality.

RESULTS

A total of 2,085 older women underwent alloplastic breast reconstruction of which 90% and 10% were IBR and DBR, respectively. Both groups had similar median age, body mass index, and frequency of smoking, diabetes mellitus, and steroid use. Tumors were mainly invasive in the IBR group (83.5%) and in situ in the DBR group (83.3%). IBR had significantly longer operative times (median 154 min vs 98 min, p < 0.0001), but equal length of stay (median 3 days vs 3 days, p = 0.1). The 30-day overall morbidity (medical or surgical complication) rate was significantly higher in the IBR group (7.5% vs 1.0%, p < 0.0004). Women with IBR were significantly more likely to develop infectious complications (6% vs 1%, p = 0.002). Cardiac/transfusion, pulmonary, thromboembolic, renal, and neurological morbidity rates were equal between groups. Thirty-day mortality rates were similar across both groups (IBR: 0.05% vs DBR: 0%, p = 0.74).

CONCLUSIONS

While overall thirty-day postoperative complication rates in older women who undergo breast reconstruction were low, there were higher rates of infectious complications in the IBR cohort. The risks and benefits of alloplastic breast reconstruction should be discussed with older women undergoing mastectomy for breast cancer treatment.

Defining unmet clinical need across the pathway of brain tumor care: a patient and carer perspective

Objective

The aim of this study was to determine the experience of patients with brain tumors and their carers across distinct parts of their treatment pathway and identify their views on potential service gaps in need of addressing.

Methods

A structured survey was administered at patient workshops across the UK and online through a charity newsletter. Answers to closed questions were analyzed using descriptive statistics, and open questions were examined using techniques of inductive content analysis.

Results

A total of 136 survey responses were received, representing patients with a variety of diagnoses and geographical locations (30 counties). There was a wide range of opinions on the provision of current neuro-oncology services. Key themes identified included a perceived lack of information provision, a gap in postdischarge psychological and neuropsychological supports, and an unmet willingness for involvement in research.

Conclusion

This national survey enhances our knowledge of current patient and carer experience within neuro-oncology services. A number of areas of unmet clinical need are highlighted providing a basis for informing future patient-centered service improvements and research.

Patients' sense of responsibility to healthcare providers and its predictors: A national cross-sectional survey in China

Objectives

To evaluate patients’ sense of responsibility to healthcare providers and to determine its predictors using on a national sample in China.

Methods

We conducted a national cross-sectional survey in China with a stratified cluster sample of patients treated in 77 hospitals between July 2014 and April 2015. Patients’ sense of responsibility to healthcare providers was measured with four questions assessing patients’ perceptions regarding their responsibilities to respect doctors, respect nurses, coordinate with health professionals, and comply with hospital rules. Predictors included patient sociodemographic characteristics and their past hospitalization experience.

Results

Small proportions of respondents reported that they perceived having no responsibility to respect doctors (8.9%), respect nurses (7.9%), comply with hospital rules (6.7%), or coordinate with health professionals (6.3%). Multivariate regression analyses showed that the strongest predictor of patients’ sense of responsibility to healthcare providers was patinets’ trust in health professionals, followed by patients’ education level. Familiarity with healthcare professionals and past hospitalization frequency were inversely associated with patients’ sense of responsibility to healthcare providers.

Conclusions

Although only a small proportion of the patients reported feeling no or low sense of responsibility to healthcare providers, the lack of respect and collaboration from these patients can negatively affect patient-provider relationships. Healthcare administrators need to communicate clearly with the patients and the public about the role of patients and the limitations of medicine in order to instill a sense of patients’ responsibility.

The impact of spine disease, relative to cranial disease, on perception of health and care experience: an analysis of 1484 patients in a tertiary center

OBJECTIVEPatient-reported outcomes have been increasingly mandated by regulators and payers to evaluate hospital and physician performance. The purpose of this study is to delineate the differences in patient-reported experience of hospital care for cranial and spinal operations.METHODSThe authors selected all patients who underwent inpatient, elective cranial or spinal procedures and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey at a single, high-volume, tertiary care institution between October 2012 and September 2015. The association of the surgical procedure and diagnosis with various HCAHPS composite measures, calculated across 9 domains using standard top-box methodology, was investigated. Multivariable logistic regression models were fitted for outcomes that were significant with procedure type and diagnosis group on univariate analysis, adjusting for age, sex, case complexity, overall health rating, and education level.RESULTSA total of 1484 patients met criteria and returned an HCAHPS survey. Overall, patients undergoing a cranial procedure gave top-box (most favorable) scores more often in pain management measure (66.3% vs 59.6%, p = 0.01) compared with those undergoing spine surgery. Furthermore, despite better discharge scores (93.1% vs 87.1%, p < 0.001), spinal patients were less likely to report excellent health (7.4% vs 12.7%). Lastly, patients with a primary diagnosis of brain or spinal tumor compared with those with degenerative spinal disease and those with other neurosurgical diagnoses provided top-box scores more often regarding communication with doctors (82.7% vs 76.4% vs 75.2%, p = 0.04), pain management (71.8% vs 60.9% vs 59.1%, p = 0.002), and global rating (90.4% vs 84.0% vs 87.3%, p = 0.02). On multivariable analysis, spinal patients had significantly lower odds of reporting top-box scores in pain management (OR 0.67, 95% CI 0.52-0.85; p = 0.001), staff responsiveness (OR 0.68, 95% CI 0.53-0.87; p = 0.002), and global rating (OR 0.59, 95% CI 0.42-0.82; p = 0.002), and significantly higher odds of top-box scoring in discharge information (OR 2.15, 95% CI 1.45-3.18; p < 0.001) than cranial patients. Similarly, brain tumor cases were associated with significantly higher odds of top-box scoring in communication with doctors (OR 1.46, 95% CI 1.01-2.12; p = 0.04), pain management (OR 1.81, 95% CI 1.29-2.55; p < 0.001), staff responsiveness (OR 1.88, 95% CI 1.33-2.66; p < 0.001), and global rating (OR 2.00, 95% CI 1.26-3.17; p = 0.003) compared with degenerative spine cases.CONCLUSIONSSignificant differences in patient-reported experience with hospital care exist across different cranial and spine surgery patient populations. Overall, spinal patients, particularly those with degenerative spine disease, rated their health and their hospital experience lower relative to cranial patients. Identifying weaker areas of hospital performance in target populations can stimulate quality initiatives that aim to increase the overall hospital score.

Factors Driving Patient Perception of Quality Care After Primary Total Hip and Total Knee Arthroplasty

Introduction:

Differences in female and male patient perception of care and satisfaction following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) were assessed via Hospital Consumer Assessment of Healthcare Providers and Systems survey, demographic, and clinical data.

Methods:

After institutional review board approval, a retrospective review of the Hospital Consumer Assessment of Healthcare Providers and Systems survey responses at a private, academic, level-I trauma center was performed from January 2011 to December 2013. Inclusion criteria were primary THA and TKA patients who were 18 years or older and returned the survey.

Results:

Overall, 1,166 THA and 1,411 TKA were included, with 55.0% of female THA patients and 64.5% of male THA patients highly satisfied (P = 0.002). The mean overall hospital rating was 7.2 for female THA and 7.8 for male THA (P = 0.003) patients. No significant differences was found in the TKA cohort. For all cohorts, the Nurse Communication with Nurses domain reported the greatest correlation with overall hospital rating (range, ρ = 0.418 to ρ = 0.502; P < 0.0001).

Discussion:

This series indicated that initiatives to improve patient care and patient perception of care should focus on nurse-patient communication, hospital staff responsiveness, the care transition process, and hospital environment. Patient sex was a significant factor in the overall satisfaction for THA, with female patients reporting significantly lower ratings than male patients.

Satisfaction with surgeon care as measured by the Surgery-CAHPS survey is not related to NSQIP outcomes

BACKGROUND

Patient satisfaction is a patient-centered outcome of particular interest. Previous work has suggested that global measures of satisfaction may not adequately evaluate surgical care, therefore the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey was developed. It remains unclear how traditional outcome measures, such as morbidity, impact patient satisfaction. Our aim was to determine whether National Surgical Quality Improvement Program-defined complications impacted satisfaction with the surgeon as measured by a surgery-specific survey, the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey.

METHODS

All patients undergoing a general surgical operation from June 2013-November 2013 were sent the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey after discharge. Retrospective chart review was conducted using the National Surgical Quality Improvement Program variable definitions, and major complications were defined. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the "best possible" or "topbox" were compared with those rated lower. Univariate and logistic regression were used to determine variable importance.

RESULTS

A total of 529 patients responded, and 71.5% (378/529) rated the surgeon as topbox. The overall National Surgical Quality Improvement Program complication rate was 14.2% (75/529), with 26.7% of those (20/75) being major complications. On univariate analysis, patients who rated their surgeon more highly were somewhat older (59 vs 54 years: P < .001), more often underwent elective surgery (81% vs 57%: P < .001), and had an increased rate of operation for malignancy (31% vs 17%). Neither the complication rate (total or major) nor the number of complications were associated with satisfaction scores.

CONCLUSIONS

When examined on a patient level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to be associated with overall patient satisfaction with surgeon care. This finding suggests that satisfaction may be an outcome distinct from traditional measures.

Official definitions for undesirable medical events : Are they correctly applied in medicine?

Background

In Austria, elaborate definitions exist for the undesirable medical events side effect, adverse event, complication and medical malpractice. We aimed at investigating whether the official definitions for the abovementioned terms can be understood by a sample population representing a cross-section of the Austrian population.

Methods

In this study 1021 Austrian citizens were interviewed. Demographic parameters (age, gender, occupation, level of education, monthly income, number of inhabitants at place of residence) were assessed. Participants were told the official definitions for complication, side effect, adverse event and medical malpractice and asked to select the correct definition for “complication”. The impact of sample characteristics on the ability to identify the correct definition was investigated.

Results

Of the participants 315 (31%) identified the correct definition of a complication. Almost the same number (n = 302, 30%; χ² for single samples: p = 0.087) falsely selected the definition for side effect. Significantly fewer (both p < 0.001) chose the definitions for adverse event (n = 220, 22%) and medical malpractice (n = 155, 15%). Only the respective state of origin showed significant influence on the probability of choosing the correct definition out of the four. The probability was highest in Vorarlberg (0.400) and lowest in Upper Austria (0.216, p < 0.001).

Conclusion

For the majority the present official definitions for undesirable medical events are too complex to understand. Simple definitions for undesirable medical events should be included into patient education.

Is quality important to our patients? The relationship between surgical outcomes and patient satisfaction

Background

With greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures.

Methods

Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction.

Results

757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47).

Conclusions

We found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Hospital Analgesia Practices and Patient-reported Pain After Colorectal Resection

OBJECTIVE

The aim of the study was to characterize patient-reported outcomes of analgesia practices in a population-based surgical collaborative.

BACKGROUND

Pain control among hospitalized patients is a national priority and effective multimodal pain management is an essential component of postoperative recovery, but there is little understanding of the degree of variation in analgesia practice and patient-reported pain between hospitals.

METHODS

We evaluated patient-reported pain scores after colorectal operations in 52 hospitals in a state-wide collaborative. We stratified hospitals by quartiles of average pain scores, identified hospital characteristics, pain management practices, and clinical outcomes associated with highest and lowest case-mix-adjusted pain scores, and compared against Hospital Consumer Assessment of Healthcare Providers and Systems pain management metrics.

RESULTS

Hospitals with the lowest pain scores were larger (503 vs 452 beds; P < 0.001), higher volume (196 vs 112; P = 0.005), and performed more laparoscopy (37.7% vs 27.2%; P < 0.001) than those with highest scores. Their patients were more likely to receive local anesthesia (31.1% vs 12.9%; P < 0.001), nonsteroidal anti-inflammatory drugs (33.5% vs 14.4%; P < 0.001), and patient-controlled analgesia (56.5% vs 22.8%; P < 0.001). Adverse postoperative outcomes were less common in hospitals with lowest pain scores, including complications (20.3% vs 26.4%; P < 0.001), emergency department visits (8.2% vs 15.8%; P < 0.001), and readmissions (11.3% vs 16.2%; P = 0.01).

CONCLUSIONS

Pain management after colorectal surgery varies widely and predicts significant differences in patient-reported pain and clinical outcomes. Enhanced postoperative pain management requires dissemination of multimodal analgesia practices. Attention to patient-reported outcomes often omitted from surgical outcomes registries is essential to improving quality from the patient's perspective.

Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly

BACKGROUND

Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients.

METHODS

A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded.

RESULTS

The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained.

CONCLUSIONS

Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities.

LEVEL OF EVIDENCE

IV.

The Effect of Timing on Breast Reconstruction Outcomes in Diabetic Women

Background:

This study examines the effect of timing (immediate vs delayed) on postoperative morbidity in diabetic women undergoing breast reconstruction after mastectomy.

Methods:

We reviewed the National Surgical Quality Improvement Program (NSQIP) databases from 2005 to 2012 for all diabetic women undergoing breast reconstruction. Multivariable logistic regression was used to estimate the risk of 30-day overall complications in the immediate versus delayed cohorts. Additionally, we retrospectively reviewed outcomes for all Johns Hopkins Hospital diabetic patients undergoing breast reconstruction from 2005 to 2014.

Results:

In the NSQIP, 1,408 diabetic women underwent breast reconstruction: 958 (68%) immediate and 450 (32%) delayed. In the immediate group, 10.75% of patients developed a 30-day overall complication, compared with 7.78% of patients in the delayed group. On multivariable analysis, the odds of developing 30-day overall complications were significantly higher (adjusted odds ratio = 1.68; P = 0.033) for the immediate compared with the delayed cohort. In the Johns Hopkins Hospital cohort, 114 reconstructions were performed in 52 diabetic women: 59 (51.8%) immediate and 55 (47.2%) delayed. On long-term follow-up (median = 16.5 months), 41.0% of immediate reconstructions developed a surgical complication compared with 27.8% of delayed reconstructions. Deep infections (P = 0.026), seroma formation (P = 0.003), reconstruction failure (P = 0.001), and reoperation rates (P = 0.001) were significantly increased in the immediate cohort.

Conclusions:

Among diabetics seeking breast reconstruction, delaying the reconstructive surgery from the mastectomy is associated with decreased postoperative morbidity. It also appears that the 30-day postoperative time point available in the NSQIP does not fully reflect the magnitude of the long-term complications these diabetic patients will develop.

Patient Satisfaction with Hospital Inpatient Care: Effects of Trust, Medical Insurance and Perceived Quality of Care

OBJECTIVE

Deteriorations in the patient-provider relationship in China have attracted increasing attention in the international community. This study aims to explore the role of trust in patient satisfaction with hospital inpatient care, and how patient-provider trust is shaped from the perspectives of both patients and providers.

METHODS

We adopted a mixed methods approach comprising a multivariate logistic regression model using secondary data (1200 people with inpatient experiences over the past year) from the fifth National Health Service Survey (NHSS, 2013) in Heilongjiang Province to determine the associations between patient satisfaction and trust, financial burden and perceived quality of care, followed by in-depth interviews with 62 conveniently selected key informants (27 from health and 35 from non-health sectors). A thematic analysis established a conceptual framework to explain deteriorating patient-provider relationships.

FINDINGS

About 24% of respondents reported being dissatisfied with hospital inpatient care. The logistic regression model indicated that patient satisfaction was positively associated with higher level of trust (OR = 14.995), lower levels of hospital medical expenditure (OR = 5.736-1.829 as compared with the highest quintile of hospital expenditure), good staff attitude (OR = 3.155) as well as good ward environment (OR = 2.361). But patient satisfaction was negatively associated with medical insurance for urban residents and other insurance status (OR = 0.215-0.357 as compared with medical insurance for urban employees). The qualitative analysis showed that patient trust-the most significant predictor of patient satisfaction-is shaped by perceived high quality of service delivery, empathic and caring interpersonal interactions, and a better designed medical insurance that provides stronger financial protection and enables more equitable access to health care.

CONCLUSION

At the core of high levels of patient dissatisfaction with hospital care is the lack of trust. The current health care system reform in China has yet to address the fundamental problems embedded in the system that caused distrust. A singular focus on doctor-patient inter-personal interactions will not offer a successful solution to the deteriorated patient-provider relationships unless a systems approach to accountability is put into place involving all stakeholders.

Admission Through the Emergency Department Is an Independent Risk Factor for Lower Satisfaction With Physician Performance Among Orthopaedic Surgery Patients: A Multicenter Study

BACKGROUND

Patient experience data are increasingly used to guide performance improvement and to determine physician and hospital reimbursement. We studied the relationship between emergency department (ED) admission and patient satisfaction with physicians' performance, and identified other associated predictors.

METHODS

We evaluated 6,524 inpatient Press Ganey patient experience surveys from two academic level I trauma centers over 5 years. We stratified patients by ED admission or other admission and compared the proportions of patients in each group who were satisfied with physician performance. We used logistic regression to control for demographic differences and characteristics of hospitalizations.

RESULTS

Among patients admitted through the ED, 85.18% were satisfied, compared with 89.44% of patients admitted through other pathways (P < 0.001). Admission through the ED predicted decreased satisfaction, with an odds ratio of 0.67 (P = 0.032) after controls were applied through logistic regression.

CONCLUSIONS

Admission through the ED is an independent risk factor for lower satisfaction with physician performance. Understanding the determinants of patient satisfaction will help improve physician-patient interactions and guide quality improvement and value-based reimbursement initiatives.

LEVEL OF EVIDENCE

This retrospective survey-based analysis of satisfaction does not fall clearly under any of the Journal's established categories of level of evidence. The most closely aligned choice would be Level III Prognostic.

Achieving a 5-star rating: Analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores among patients undergoing elective colorectal operations

BACKGROUND

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patients' hospital experience.

METHODS

All inpatient, elective colorectal resections with completed HCAHPS surveys at a single institution between June 2012 and April 2015 were identified. HCAHPS measures were analyzed according to published methodologies. Univariate logistic regression evaluated associations of various HCAHPS measures with age, sex, ostomy, approach, diagnosis, and prolonged length of stay (PLOS; ≥7 days). Key driver analysis demonstrated associations between the individual HCAHPS measures and the global hospital rating measure.

RESULTS

We identified 755 patients. Younger age, inflammatory bowel disease, open approach, ostomy construction, and PLOS were associated with low quality of pain management. Patients with inflammatory bowel disease, open approach, and PLOS had a low overall star score (all P < .05). Care transitions and communication about medications received low scores but were associated highly with the global hospital rating measure.

CONCLUSION

Efforts aimed at improving pain management among patients with colorectal resection should focus on patients with inflammatory bowel disease, open operations, ostomies, and PLOS. Improving care transitions and communication about medications are important targets for improvement to increase the overall hospital score. Considering the importance of improving patient-centered outcomes, we suggest that all institutions utilize their existing HCAHPS data in this manner.

Factors influencing inpatients' satisfaction with hospitalization service in public hospitals in Shanghai, People's Republic of China

OBJECTIVE

The aim of this study was to observe the current status of inpatient satisfaction and analyze the possible factors influencing patient satisfaction during hospitalization.

METHODS

A cross-sectional investigation was conducted to obtain basic information about inpatient satisfaction, and statistical methods were used to describe and analyze the data. A total of 878 questionnaires were included in this study. A 5-point Likert scale rating was employed to assess items related to hospitalization care. Nonparametric tests and ordinal logistic analysis were used to explore the relationship between predictors and the patients' overall satisfaction.

RESULTS

Among the respondents, 89.75% were satisfied overall with the service they received during hospitalization, while 0.57% reported dissatisfaction. Inpatient demographic characteristics such as sex of the patients, occupation, age, and residence had significant associations with satisfaction, while monthly income and marital status did not. Additionally, the statistical outcome indicated that doctors' and nurses' service attitudes, and expenditure and environment were found to have an impact on the inpatient satisfaction ratings, with odds ratio of 2.43, 3.19, and 2.72, respectively.

CONCLUSION

This study emphasizes the influence of sex of the patients, the service attitudes of the doctors and nurses, and expenditure and environment on inpatient satisfaction. An increase in satisfaction ratings concerning the areas of doctors' and nurses' service attitudes, and expenditure and environment can improve the overall satisfaction levels. Responsible health management departments should pay attention to patient satisfaction and improve the quality of relevant health services, thus ultimately enhancing inpatients' hospitalization experiences.

Surgical Baseball Cards: Improving Patient- and Family-Centered Care

OBJECTIVE

Busy surgical services with diverse team members and frequent handoffs create barriers to patient- and family-centered care. The aim of this study was to determine whether the use of cards containing team member names, roles, and photographs-"Surgical Baseball Cards" (SBCs)-would improve patient recognition of caregivers and whether this would improve patient satisfaction.

DESIGN

A prospective, controlled study was performed of all adult patients admitted to 2 academic acute care general surgery services with alternating admitting days. Surgical team members on one service had SBCs to give patients at introduction, whereas the control service used no such tool. Before discharge, patients completed a survey consisting of a quiz requiring matching of caregiver photographs to names and roles (5-point maximum), questions rating select elements of patient satisfaction (5-point Likert scale), and an opportunity to provide comments.

SETTING

Department of Surgery, University of Michigan, Ann Arbor, MI, a university teaching hospital.

PARTICIPANTS

A total of 162 patients were included over 2 months, with at least a 24-hour admission to an acute care general surgery service.

RESULTS

Overall, 60% of patients in the intervention arm received SBCs. Per-unit SBC cost was 0.16 USD. Patients who received SBCs had significantly improved identification of team members based on name (1.7 ± 1.4 vs 1.2 ± 1.5, p = 0.02) and role (1.6 ± 1.4 vs 0.9 ± 1.2, p = 0.02) than controls did. All the SBC recipients and 88% of controls felt that SBCs should be implemented hospital-wide. SBC recipients reported a trend toward increased comfort with resident involvement in care (4.6 ± 0.7 vs 4.5 ± 0.9, p = 0.14). Among themes discerned from free-response comments, 46% of SBC recipients commented on the innovative nature of SBCs and 29% noted improved team identification. Overall, 17% of SBC recipients commented positively on patient-centered care (vs 3% of controls), whereas 5% commented negatively on patient-centered care (vs 15% of controls); 8% of SBC recipients commented positively on coordination of care (vs 1% of controls), whereas 5% commented negatively on coordination of care (vs 24% of controls).

CONCLUSIONS

SBCs provide reasonable value by improving patient recognition of healthcare team members and understanding of team member roles, and they are associated with positive patient feedback regarding coordination of care and patient-centered care.

Understanding the determinants of patient satisfaction with surgical care using the Consumer Assessment of Healthcare Providers and Systems surgical care survey (S-CAHPS)

BACKGROUND

Patient satisfaction has been emphasized increasingly in all aspects of medicine, including the imposition of financial penalties for underperformance. Current measures of patient satisfaction, however, do not address aspects specific to the care of operative patients. Therefore, our aim was to examine the recently validated Consumer Assessment of Healthcare Providers and Systems (S-CAHPS) to determine which aspects of perioperative care are predictive of satisfaction with the surgeon.

METHODS

All patients undergoing a general surgery operation at our institution during a 5-month period were sent a modified S-CAHPS within 3 days of discharge. Patients were then divided into 2 groups: those who rated their surgeon as the best possible and those giving a lower rating. Univariate and multivariate analyses were used to determine predictors of satisfaction with operative care. S-CAHPS results were then compared with other satisfaction measures in a subset of patients.

RESULTS

The response rate was 45.3% (456/1,007). The average age was 59 ± 16 years, duration of stay was 4.1 ± 6.6 days, and 23% underwent unscheduled operations. A total of 72% of patients rated their surgeon as the best surgeon possible. On multivariate analysis, preoperative communication and attentiveness on the day of operation were the most important determinants of overall surgeon rating. S-CAHPS scores correlated with other standard measures of satisfaction (HCAHPS scores).

CONCLUSION

S-CAHPS is a novel operative satisfaction tool and is feasible to administer to patients undergoing general operative procedures. Surgeon characteristics most predictive of high patient satisfaction are effective preoperative communication and attentiveness on the day of operation.

Acute Pain Medicine in the United States: A Status Report

BACKGROUND

Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs.

METHODS

A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education.

RESULTS

The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM.

CONCLUSION

This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.