Propublica released data earlier this year describing surgery rates and complications. With the data's release, many medical providers, including members of North American Spine Society, are discussing how the public has tremendous information about care and practices, and how more data will be available in the future for both the public and payers.
William Ryan Spiker, MD, assistant professor in the department of orthopedic surgery at the University of Utah in Salt Lake City, presented at a symposium on the factors influencing patient satisfaction at NASS' 30th Annual Meeting held in Chicago.
Patients can readily access not only a provider's score, but exactly what the score is comprised of in different subcategories. "Patient satisfaction is designed so that we understand the experience of the patient," Dr. Spiker said. "They are the customer. They are what we are trying to improve, and we need to know how they are doing, not just how we think they are doing." The emphasis on patient satisfaction begs the question as to whether patient satisfaction scores are/are not synonymous with quality.
The Affordable Care Act of 2010 created the Hospital-Value Based Purchasing Program in which Medicare creates incentive payments to hospital based upon patient experience. Outpatient patient satisfaction scores, rather, are linked to physician and hospital ratings which are accessible online. Dr. Spiker said the role outpatient patient satisfaction scores will have in the near future is unknown.
Healthcare providers are determining the best way to access patient satisfaction. "For outpatient care, the most commonly used survey is the Press Ganey Medical Practice Survey," explained Dr. Spiker. "What this survey is, is a combination of 24 questions in six different subdomians that tries to understand a patient's experience as it relates to issues such as access, timing, care of nurse as well as care of provider and overall experience of the patient."
Dr. Spiker then detailed data collected at the University of Utah pertaining to patient satisfaction scores. The data reveals a "huge right shift." Dr. Spiker said, "Almost everyone is doing fairly well in terms of patient satisfaction."
Because the Press Ganey Survey is based on a percentile rank, a very small change in actual satisfaction score results in a large percentile change. Dr. Spiker explained this is "one of many statistical issues with the survey."
Inpatient satisfaction scores, on the other hand, are generally based on the Hospital Consumer Assessment of Healthcare Providers and Systems. HCAHPS consists of 21 questions based on the patient experience as well as some demographic questions. HCAHPS looks at issues concerning the responsiveness of staff, pain management, communication between the nurses and the patient as well as communication between the physicians and the patient. It also examines the cleanliness and quietness of hospital and discharge information provided.
"We look at these satisfaction surveys, both inpatient and outpatient, and we say 'Okay this is what we are measuring, but what does it really mean?'" said Dr. Spiker.
Physicians understand the significance of various demographic and psychological factors, as they can greatly influence a patient's satisfaction score. However, physicians, for the most part, do not know to what extent. At this point, the relationship of patient satisfaction to functional outcomes is largely unknown.
Dr. Spiker went on to detail non-spine literature that included the factors that influence patient satisfaction including age, gender, race, education, insurance, employment status and self-reported health status. The "I'm Satisfied" studies are dichotomous; they ask patients whether they are (a) satisfied or (b) not satisfied.
"These studies certainly provide some good information and have identified some risk factors within the spine clinic population," said Dr. Spiker. One study analyzed 1,600 patients approximately one year follow-up post spine surgery. They found 83 percent of patients self-reported as satisfied and the two risk factors impact satisfaction scores were the insurance status of the patient and the severity of disability. Patients with Medicaid were generally less satisfied, and the patients with a more severe disability were less satisfied.
"This brought to the forefront the idea that we can't just ask if patients are satisfied," said Dr. Spiker. "We need to know more about them before we rate providers or hospitals based on the satisfaction number."
A key issue with the "I'm Satisfied Studies" is they are similar to the good versus poor outcome studies. While they provide some quality information, they may not serve as the best tool to assess patient satisfaction. These studies led University of Researchers to conduct a study analyzing the impact of non-modifiable patient factors on patient satisfaction.
The retrospective study of 12,177 clinical encounters recorded the age, gender, employment status, zip code and insurance provider of the patient to determine the risk factor for low patient satisfaction scores. In the study, researchers found older patients reported greater satisfaction, as well as patients who traveled farther reported higher levels of satisfaction. Gender, subspecialty, insurance status and employment status did not have a substantial effect on patient satisfaction scores.
In a different study, researchers analyzed the impact of demographics and its relationship to functional outcomes in 231 patients from the Spine Surgery Clinic and recorded age, gender, ASA score as well as their visit type and ODI score among others. The findings indicate, like the previous study, older patients reported higher satisfaction scores. Additionally, return patients had higher satisfaction scores. Researchers did not find a significant correlation between the functional outcome measures and patient satisfaction scores.
"There have been many, many studies looking at the effect psychological distress has on functional outcomes," said Dr. Spiker. "But there has been nothing looking at patient satisfaction. We know that patients coming to the Spine Clinic have higher rates of psychological distress, and the question is, does that impact their satisfaction score?"
To answer that question, Dr. Spiker and researchers looked at 103 patients over a course of two years. The patients at the Spine Clinic filled out a Distress and Risk Assessment Method Questionnaire as well as Press Ganey Satisfaction Score. "Within these groups, we found basically half the patients were normal, about a quarter was at risk and a quarter was distressed," said Dr. Spiker. Of the distressed patients, 13 patients were distressed depressive and 12 patients were distressed somatic.
The patients that were distressed had lower scores for their overall satisfaction. Researchers found patients with psychological distress had a changed perception of symptoms and perception of care received.
Based on the studies' results, researchers concluded patients' inherent qualities impact their care including age, emotional distress, visit type, expectations and possibly disability.
"Satisfaction is not a surrogate for outcomes measures. The association is still unclear at this time," said Dr. Spiker. "But, it appears to be its own, individual measure. Therefore, maybe patient satisfaction is part of the quality equation, but it is not synonymous with quality."