Is satisfaction among orthopaedic trauma patients predicted by depression and activation levels?

An Analysis of Formal Patient Complaints, Risk, and Malpractice Events Involving Orthopedic Trauma Surgeons During a 10-Year Period

Formal patient complaints and malpractice events involving orthopedic trauma surgeons (OTSs) can have substantial career implications. Our purpose was to analyze formal patient complaints, risk events, and malpractice events against OTSs during a 10-year period. We reviewed all formal patient complaints within our institution's patient advocacy database involving 9 fellowship-trained OTSs throughout a decade. Complaints were categorized using the Patient Complaint Analysis System. Potential risk and malpractice events involving the OTSs were recorded. A control group of all patients seen by the surgeons during the study period was created. Demographics between patients with complaints and the control group were analyzed, as were malpractice, risk, and complaint rates between the surgeons. Of 33,770 patients, 136 filed a formal complaint (0.40%). There were 29 malpractice claims and 2 malpractice lawsuits. The care and treatment domain accounted for the highest percentage of complaints (36%), followed by the access and availability domain (26%). Results of the logistic regression analysis indicated that private insurance (odds ratio, 1.58) and operative treatment (odds ratio, 3.65) were significantly associated with complaints. Despite statistically significant differences in the rates of complaint and risk events between surgeons, malpractice events did not differ. The rate of patient complaints within a large orthopedic trauma practice during a 10-year period was 0.40%. Patients with private insurance and those treated operatively were more likely to file a complaint. Whereas complaint rates among surgeons varied, there was no significant difference in the rate of malpractice events. Understanding patient complaint rates and categorizations may allow surgeons to target areas for improvement. [Orthopedics. 2023;46(2):121-127.].

Countersinking the Lag Screw or Blade During Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures: Less Collapse and Implant Prominence Without Increased Cutout Rates

INTRODUCTION

The lag screw or helical blade of a cephalomedullary nail facilitates controlled collapse of intertrochanteric proximal femur fractures. However, excessive collapse results in decreased hip offset and symptomatic lateral implants. Countersinking the screw or helical blade past the lateral cortex may minimize subsequent prominence, but some surgeons are concerned that this will prevent collapse and result in failure through cutout. We hypothesized that patients with countersunk lag screws or helical blades do not experience higher rates of screw or blade cutout and have less implant prominence after fracture healing.

METHODS

A retrospective review of 175 consecutive patients treated with cephalomedullary nails for AO/OTA 31A1-3 proximal femur fractures and a minimum 3-month follow-up and 254 patients with a 6-week follow-up at a single US level I trauma center. Patients were stratified based on countersunk versus noncountersunk lag screw or helical blade in a cephalomedullary nail. The primary outcome was the cutout rate at minimum 3 months, and the secondary outcome was radiographic collapse at minimum 6 weeks.

RESULTS

Cutout rates were no different in patients with countersunk and noncountersunk screws and blades, and countersinking was associated with less collapse and less implant prominence at 6 weeks.

DISCUSSION

Surgeons can countersink the lag screw or blade when treating intertrochanteric proximal femur fractures with a cephalomedullary nail without increasing failure rates and with the potential benefits of less prominent lateral implants and decreased collapse.

Patient Satisfaction Is Improved With Exposure to Trauma Recovery Services

INTRODUCTION

The purpose of this study is to assess the impact of Trauma Recovery Services (TRS), a program facilitating engagement and recovery on satisfaction after orthopaedic trauma.

METHODS

Two hundred ninety-four patients with surgically managed extremity fractures were prospectively surveyed. Satisfaction was assessed after 12 months using a 13-question telephone survey, rated on a Likert scale from 1 to 5 (with five being excellent). TRS resource utilization during and after hospitalization was recorded. Eighty-eight patients (30%) used TRS.

RESULTS

Overall satisfaction was high with a mean score of 4.32. Although no differences were observed between the control group and patients with TRS utilization in age, sex, race, insurance, smoking history, or employment status, TRS patients sustained more high-energy mechanisms (81% versus 56%) and had more associated psychiatric illness (33% versus 17%), both P < 0.01. Multivariable regression indicated general exposure to TRS to be an independent predictor of higher overall care ratings (B = 1.31; P = 0.03).

DISCUSSION

Utilization of TRS was the greatest predictor of better overall care ratings. This study builds on existing evidence demonstrating the positive impact of Trauma Survivor Network programming. We conclude that a hospital-wide program supporting patient education and engagement can effectively increase patient satisfaction after traumatic injury.

LEVEL OF EVIDENCE

Prognostic Level II.

Implementing psychosocial programming at a level 1 trauma center: results from a 5-year period

BACKGROUND

The primary goal of the present study is to describe the psychosocial support services provided at our institution and the evolution of such programming through time. This study will also report the demographics and injury patterns of patients using available resources.

METHODS

Trauma Recovery Services (TRS) is a social and psychological support program that provides services and resources to patients and families admitted to our hospital. It includes a number of different services such as emotional coaching from licensed counselors, educational materials, peer mentorship from trauma survivors, monthly support groups, post-traumatic stress disorder (PTSD) screening and programming for victims of crime. Patients using services were prospectively recorded by hired staff, volunteers and students who engaged in distributing programming. Demographics and injury characteristics were retrospectively gathered from patient's medical records.

RESULTS

From May of 2013 through December 2018, a total of 4977 discrete patients used TRS at an urban level 1 trauma center. During the study period, 31.4% of the 15 640 admitted adult trauma patients were exposed to TRS and this increased from 7.2% in 2013 to 60.1% in 2018. During the period of 5.5 years, 3317 patients had 'direct contact' (coaching and/or educational materials) and 1827 patients had at least one peer visit. The average number of peer visits was 2.7 per patient (range: 2-15). Of the 114 patients who attended support groups over 4 years, 55 (48%) attended more than one session, with an average of 3.9 visits (range: 2-10) per patient. After the establishment of PTSD screening and Victims of Crime Advocacy and Recovery Program (VOCARP) services in 2017, a total of 482 patients were screened for PTSD and 974 patients used VOCARP resources during the period of 2 years, with substantial growth from 2017 to 2018.

CONCLUSIONS

Hospital-provided resources aimed at educating patients, expanding support networks and bolstering resiliency were popular at our institution, with nearly 5000 discrete patients accessing services during a period of 5.5 years. Moving forward, greater investigation of program usage, development, and efficacy is necessary.

LEVEL OF EVIDENCE

Level II therapeutic.

Implementing recovery resources in trauma care: impact and implications

Objectives:

To identify resources that patients perceive as helpful to their recovery and to characterize the impact of the Trauma Survivor Network (TSN), a program committed to enhancing recovery through education and engagement.

Design:

Prospective cohort study.

Setting:

Level 1 trauma center.

Patients/Participants:

Four hundred eighty-five patients with musculoskeletal injuries. Two hundred eleven were exposed to TSN resources (Group 1). One hundred thirty-five patients were treated during the same period with no exposure (Group 2, control). One hundred thirty-nine patients were treated 1 to 3 months prior to TSN implementation (Group 3, control).

Intervention:

TSN resources including educational materials, family classes, peer survivor visits, coaching, online services, and support groups.

Main outcome measure:

A survey to assess hospital experience and perceptions about recovery.

Results:

On a Likert scale from 0 to 5, patients were highly satisfied (mean 4.24), with no differences based on TSN exposure. Patients exposed to TSN programming reported greater perceived likelihood of recovery: mean 3.73 vs 3.41 vs 3.38, Group 1 vs Group 2 vs Group 3 (P = .05) and regarding return to daily activities: 3.69 vs 3.49 vs 3.10, P = .003. Fifty-three percent of Group 1 patients exposed to TSN programming utilized peer relationships and 42% read the educational materials provided. Support groups were also popular, with 26% of patients attending at least 1 session. Patients who recalled utilization of TSN services were overall highly satisfied with these services, mean 4.42.

Conclusion:

Patients were overall highly satisfied with their hospital stay, with those exposed to TSN services reporting greater perceived likelihood of recovery and return to daily activities. Development of nontraditional services, including peer visitation and support groups, appears to enhance expectations about recovery.

Patient-Reported Outcome Measures and Patient Activation: What Are Their Roles in Orthopedic Trauma?

The rise of patient-reported outcome (PRO) measurement across medicine has been swift and now extends to the world of orthopedic trauma. However, PRO measures (PROMs) applied to trauma patients pose special considerations; measuring "episodes of care" is less straightforward, injuries are heterogeneous in their severity, and the patient's initial visit is "postinjury." Obtaining baseline scores and assessing the impact of a traumatic event on mental health are key considerations. Currently, few, if any, trauma registries include PROs; though general and condition-specific PROMs plus the patient empowerment measure of Patient Activation represent meaningful inputs for the clinical decision-making process. To be useful in trauma care, PROMs should be psychometrically sound and validated, be used for capturing function, screen for mental state and substance use, and give the clinician a sense of the patient's "activation" (engagement in their own health). Although the implementation of routine PRO collection can seem daunting, clinicians can use a multitude of electronic resources to access validated measures and simplify the implementation process. Computer-adaptive testing has evolved to help minimize patient burden, and PROM collection must maximize efficiency. Once established as part of your practice, PROs become an important tool to track recovery, identify mental health issues, engage in the prevention of future injury, and enable care of the whole patient.

The Effect of a Tailored Patient Activation Intervention in Inflammatory Bowel Disease Patients

Purpose A pre-test, post-test, control group design was employed to investigate the impact of a tailored patient activation intervention (PAI) among inflammatory bowel disease (IBD) patients. Methods Patients who met the inclusion criteria were selected from medical records via convenience sampling, were consented, and completed a baseline survey. Based on responses to the baseline 13-item patient activation measure (PAM-13), they were categorized into one of four patient activation stages. During office visits, intervention patients (N=23) were given a tailored PAI based on their baseline stage, which consisted of an information booklet and focused discussion with the gastroenterologist, while the control group (N=27) received usual care. Baseline and 1-month post-intervention scores were compared between the intervention (N=20) and control (N=21) groups for changes in patient activation score, medication adherence, and satisfaction with care. Results Most participants were Caucasian (88%), female (64%), college graduates (56%), and had Crohn's disease (59.2%). Overall, females had a significantly higher (p=0.04) mean activation score (mean=70.9±15.4) than males (mean=60.9±10.7) at baseline. This trend was the same post-intervention (75.6 females vs 64.4 males; p=0.03). The difference in mean activation scores pre- vs post-intervention was not statistically significant between the intervention and control groups (mean=4.9±12.3, p=0.21). However, this difference could be considered to be clinically significant based on results from previous studies. There were no significant differences in medication adherence or satisfaction scores pre- vs post-intervention for either group. Conclusion Tailored PAIs have the potential to increase activation level of patients with inflammatory bowel disease. This customized medical interaction increased patient involvement in disease management and could potentially lead to improved health outcomes.

Effect of Mental Health Conditions on Complications, Revision Rates, and Readmission Rates Following Femoral Shaft, Tibial Shaft, and Pilon Fracture

OBJECTIVES

To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures.

DESIGN

Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions.

SETTING

National databases of 70 million combined patients from 2007 to 2015.

PATIENTS/PARTICIPANTS

Humana and Medicare insured patients.

INTERVENTION

Surgical treatment of tibial, femoral, and pilon fractures.

MAIN OUTCOME MEASUREMENTS

Ninety-day readmission, 90-day complications, and all-time revision surgical intervention.

RESULTS

The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all).

CONCLUSIONS

Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mental illness is associated with more pain and worse functional outcomes after ankle fracture

Objectives

To assess clinical and functional outcomes after ankle fracture in patients with preexisting mental illness.

Design

Retrospective study.

Setting

Level 1 trauma center.

Patients/Participants

One thousand three hundred seventy-eight adult patients treated for ankle fractures; 228 (17%) had preexisting mental illness.

Intervention

Open reduction internal fixation.

Main outcome measure

Rates of complications and reoperations. Functional outcomes were assessed via Foot Function Index (n = 530) and Short Musculoskeletal Function Assessment (n = 530).

Results

Depression was the most common mental illness (63%), followed by anxiety (23%). Mental illness was associated with older age, female sex, and preexisting medical comorbidities, including diabetes and obesity. Mental illness was not associated with specific fracture patterns or open injury. Complications occurred no more often in patients with mental illness, but secondary operations (13% vs 7%) were more likely, particularly implant removals (8% vs 4%), both P < .05. Functional outcomes were worse in mentally ill patients as measured by the Foot Function Index (39 vs 30, P = .006) and Short Musculoskeletal Function Assessment Mobility: 45 vs 35, Bothersome: 35 vs 26 and Dysfunction: 35 vs 26, all P < .01.

Conclusion

Secondary operations were nearly 50% more frequent in patients with mental illness, and functional outcome scores were significantly worse, suggesting that mental illness, unrelated to injury and treatment parameters, has major influence on outcomes. In the future, strategies to identify and treat mental illness prior to and after treatment could improve functional outcomes following ankle fracture.

Self-Reported Recovery Likelihood Predicts Higher Physician Ratings: A Survey of Patients After Orthopaedic Surgery

OBJECTIVES

What are the differences between elective and trauma patient satisfaction and do patient and diagnosis factors predict physician scores?

DESIGN

Prospective cohort study.

SETTING

Urban Level 1 Trauma center.

PATIENTS/PARTICIPANTS

Three hundred twenty-three trauma patients and 433 elective orthopaedic patients treated at our center by the same surgeons.

INTERVENTION

Trauma patients treated surgery for one or more fractures; elective patients treated with hip, knee, or shoulder arthroplasty, or rotator cuff repair.

MAIN OUTCOME MEASUREMENTS

Telephone survey regarding patient experience and satisfaction with their care. The survey included questions from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, and responses were rated on a 1-5 point Likert scale (5 best).

RESULTS

Elective surgery patients had mean age of 56.4 years, and trauma patients were mean 50.3 years of age. Trauma patients rated their likelihood to make a full recovery lower than elective patients (median, interquartile range), 5.0 (1.0) versus 4.0 (2.0) (P < 0.001). After multivariate binary logistic regression, patients who rated the hospital higher (≥4 vs. ≤3) were more likely (odds ratio = 10.0, 95% confidence interval, 6.4-15.8) to score physicians better. Similarly, patients who scored their overall likelihood of recovering ≥4 compared with ≤3 were more likely (odds ratio = 3.6, 95% confidence interval, 2.9-5.6) to rate their physicians more positively.

CONCLUSIONS

Patient perceptions including their likelihood to make a full recovery and their overall impression of the hospital predicted higher physician scores. We conclude that these physician scores are subject to patient perception biases and are not independent of the overall care experience. We recommend HCAHPS and physician ratings' web sites include internal controls, such as the patient perception of overall likelihood to recover, to aid in interpreting survey results.

Health Literacy and Education as Mediators of Racial Disparities in Patient Activation Within an Elderly Patient Cohort

The Patient Activation Measure (PAM) assesses facets of patient engagement to identify proactive health behaviors and is an important predictor of health outcomes. Health literacy and education are also important for patient participation and successful navigation of the health care system. Because health literacy, education, and patient activation are associated with racial disparities, we sought to investigate whether health literacy and education would mediate racial differences in patient activation. Participants were 265 older adults who participated in a computer-based exercise interventional study. Health literacy was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Of 210 eligible participants, 72% self-identified as Black and 28% as White. In adjusted analyses, education and health literacy each significantly reduced racial differences in patient activation. These findings are especially important when considering emerging data on the significance of patient activation and new strategies to increase patient engagement.

Patient Activation and Mental Health Care Experiences Among Women Veterans

We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.

A Systematic Review of Outcome Measures Assessing Disability Following Upper Extremity Trauma

Objectives

To define upper extremity outcome measures focusing on trauma and level of initial psychometric evaluation and to assess methodological quality of relevant patient-reported outcome (PRO) measures.

Data Sources

A broad search strategy using PubMed, OVID, CINAHL, and PsycINFO was deployed and reported using PRISMA (PROSPERO: CRD42016046243).

Study Selection Extraction Synthesis

PRO measures involving orthopedic trauma in their original development were selected and original publications assessed, including psychometric evaluations. Extraction, synthesis, and quality assessment were performed using COSMIN.

Results

Of 144 upper extremity outcome measures, the majority were designed for the shoulder, wrist, and hand; 20% (n = 29/144) involved trauma conditions in their initial development, PRO measurements, and psychometric evaluation on introduction. Methodological quality was highly variable.

Conclusion

A few PRO measures were originally designed for use in upper extremity trauma. Methodological quality and psychometric evaluation need to improve. This review aims to highlight strengths and weaknesses and guide decision making in this field.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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