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Jay M. Levin, Robert D. Winkelman, Joseph E. Tanenbaum, Edward C. Benzel, Thomas E. Mroz and Michael P. Steinmetz

OBJECTIVE

The Patient Experience of Care, composed of 9 dimensions derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is being used by the Centers for Medicare & Medicaid Services to adjust hospital reimbursement. Currently, there are minimal data on how scores on the constituent HCAHPS items impact the global dimension of satisfaction, the Overall Hospital Rating (OHR). The purpose of this study was to determine the key drivers of overall patient satisfaction in the setting of inpatient lumbar spine surgery.

METHODS

Demographic and preoperative patient characteristics were obtained. Patients selecting a top-box score for OHR (a 9 or 10 of 10) were considered to be satisfied with their hospital experience. A baseline multivariable logistic regression model was then developed to analyze the association between patient characteristics and top-box OHR. Then, multivariable logistic regression models adjusting for patient-level covariates were used to determine the association between individual components of the HCAHPS survey and a top-box OHR.

RESULTS

A total of 453 patients undergoing lumbar spine surgery were included, 80.1% of whom selected a top-box OHR. Diminishing overall health status (OR 0.63, 95% CI 0.43–0.91) was negatively associated with top-box OHR. After adjusting for potential confounders, the survey items that were associated with the greatest increased odds of selecting a top-box OHR were: staff always did everything they could to help with pain (OR 12.5, 95% CI 6.6–23.7), and nurses were always respectful (OR 11.0, 95% CI 5.3–22.6).

CONCLUSIONS

Patient experience of care is increasingly being used to determine hospital and physician reimbursement. The present study analyzed the key drivers of patient experience among patients undergoing lumbar spine surgery and found several important associations. Patient overall health status was associated with top-box OHR. After adjusting for potential confounders, staff always doing everything they could to help with pain and nurses always being respectful were the strongest predictors of overall satisfaction in this population. These findings highlight opportunities for quality improvement efforts in the spine care setting.

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Gabriel A. Smith, Steven Chirieleison, Jay Levin, Karam Atli, Robert Winkelman, Joseph E. Tanenbaum, Thomas Mroz and Michael Steinmetz

OBJECTIVE

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, completed by patients following an inpatient stay, are utilized to assess patient satisfaction and quality of the patient experience. HCAHPS results directly impact hospital and provider reimbursements. While recent work has demonstrated that pre- and postoperative factors can affect HCAHPS results following lumbar spine surgery, little is known about how these results are influenced by hospital length of stay (LOS). Here, the authors examined HCAHPS results in patients with LOSs greater or less than expected following lumbar spine surgery to determine whether LOS influences survey scores after these procedures.

METHODS

The authors conducted a retrospective review of HCAHPS surveys, patient demographics, and outcomes following lumbar spine surgery at a single institution. A total of 391 patients who had undergone lumbar spine surgery and had completed an HCAHPS survey in the period between 2013 and 2015 were included in this analysis. Patients were divided into those with a hospital LOS equal to or less than the expected (LTE-LOS) and those with a hospital LOS longer than expected (GTE-LOS). Expected LOS was based on the University HealthSystem Consortium benchmarks. Nineteen questions from the HCAHPS survey were examined in relation to patient LOS. The primary outcome measure was a comparison of “top-box” (“9–10” or “always or usually”) versus “low-box” (“1–8” and “somewhat or never”) scores on the HCAHPS questions. Secondary outcomes of interest were whether the comorbid conditions of cancer, chronic renal failure, diabetes, coronary artery disease, hypertension, stroke, or depression occurred differently with respect to LOS. Statistical analysis was performed using Fisher’s exact test for the 2 × 2 contingency tables and the chi-square test for categorical variables.

RESULTS

Two hundred fifty-seven patients had an LTE-LOS, whereas 134 patients had a GTE-LOS. The only statistically significant difference in preoperative characteristics between the patient groups was hypertension, which correlated to a shorter LOS. A GTE-LOS was associated with a decreased likelihood of a top-box score for the HCAHPS survey items on doctor listening and pain control.

CONCLUSIONS

Here, the authors report a decreased likelihood of top-box responses for some HCAHPS questions following lumbar spine surgery if LOS is prolonged. This study highlights the need to further examine the factors impacting LOS, identify patients at risk for long hospital stays, and improve mechanisms to increase the quality and efficiency of care delivered to this patient population.

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Haariss Ilyas, Joshua L. Golubovsky, Jingxiao Chen, Robert D. Winkelman, Thomas E. Mroz and Michael P. Steinmetz

OBJECTIVE

The objective of this study was to evaluate the incidence and risk factors for 90-day readmission and reoperation after elective surgery for lumbar spinal stenosis (LSS).

METHODS

The authors performed a retrospective consecutive cohort analysis of patients undergoing posterior lumbar decompression with or without fusion for LSS with claudication from January 2014 through December 2015.

RESULTS

Data were collected on 1592 consecutive patients. The mean age at surgery was 67.4 ± 10.1 years and 45% of patients were female. The 90-day reoperation rate was 4.7%, and 69.3% of the reoperations occurred within the first 30 days. The 90-day readmission rate was 7.2%. Multivariable analysis showed that postoperative development of a surgical site infection (SSI; odds ratio [OR] 14.09, 95% confidence interval [CI] 7.86–25.18), acute kidney injury (AKI; OR 6.76, 95% CI 2.39–19.57), and urinary tract infection (UTI; OR 3.96, 95% CI 2.43–6.37), as well as a history of congestive heart failure (CHF; OR 3.03, 95% CI 1.69–5.28), were significant risk factors for readmission within 90 days. Male sex (OR 0.60, 95% CI 0.38–0.92) was associated with decreased odds for readmission. With regards to reoperation, development of SSI (OR 25.06, 95% CI 13.54–46.51), sepsis (OR 7.63, 95% CI 1.52–40.59), UTI (OR 2.54, 95% CI 1.31–4.76), and increased length of stay (LOS; OR 1.25, 95% CI 1.17–1.33) were found to be significant risk factors. A subsequent analysis found that morbid obesity (OR 6.99), history of coronary artery disease (OR 2.263), increased duration of surgery (OR 1.004), and LOS (OR 1.07) were significant risk factors for developing an SSI.

CONCLUSIONS

Overall, this study found rates of 4.7% and 7.2% for reoperation and readmission, respectively, within 90 days: 30.7% of the reoperations and 44.7% of the readmissions occurred beyond the first 30 days. A diagnosis of SSI, AKI, UTI, and history of CHF were significant factors for readmission, while male sex was associated with decreased odds for readmission. A diagnosis of SSI, sepsis, UTI, and increased LOS were found to be significant predictors for reoperation. Understanding 90-day complication rates is imperative because there has been increased discussion and healthcare policy extending the global postoperative window to 90 days. Current literature supports a readmission rate of 3%–9% after spine surgery. However, this literature either is limited to a 30-day window or does not stratify between different types of spine surgeries.