The association between patient rating of their spine surgeon and quality of postoperative outcome

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  • 1 Center for Spine Health, Cleveland Clinic;
  • | 2 Case Western Reserve University School of Medicine, Cleveland;
  • | 3 Department of Neurosurgery, Cleveland Clinic; and
  • | 4 Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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OBJECTIVE

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey was developed by the Centers for Medicare and Medicaid Services as a result of their value-based purchasing initiative. It allows patients to rate their experience with their provider in the outpatient setting. This presents a unique situation in healthcare in which the patient experience drives the marketplace, and since its creation, providers have sought to improve patient satisfaction. Within the spine surgery setting, however, the question remains whether improved patient satisfaction correlates with improved outcomes.

METHODS

All patients who had undergone lumbar spine surgery between 2009 and 2017 and who completed a CG-CAHPS survey after their procedure were studied. Demographic and surgical characteristics were then obtained. The primary outcomes of this study include patient-reported health outcomes measures such as the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) surveys for both mental health (PROMIS-GH-MH) and physical health (PROMIS-GH-PH), and the visual analog scale for back pain (VAS-BP). A multivariable linear regression analysis was used to assess whether patient satisfaction with their provider was associated with changes in each health status measure after adjusting for potential confounders.

RESULTS

The study population included 647 patients who had undergone lumbar spine surgery. Of these, 564 (87%) indicated that they were satisfied with the care they received. Demographic and surgical characteristics were largely similar between the two groups. Multivariable linear regression demonstrated that patient satisfaction with their provider was not a significant predictor of change in two of the three patient-reported outcomes (PROMIS-GH-MH and PROMIS-GH-PH) assessed at 1 year. However, top-box patient satisfaction with their provider was a significant predictor of improvement in VAS-BP scores at 1 year.

CONCLUSIONS

The authors found that after adjusting for patient-level covariates such as age, diagnosis of disc displacement, self-reported mental health, self-reported overall health, and preoperative patient-reported outcome measure status, a significant association was observed between top-box overall provider rating and 1-year improvement in VAS-BP, but no such association was observed for PROMIS-GH-PH and PROMIS-GH-MH. This suggests that pain-related outcome measures may serve as better predictors of patients’ satisfaction with their spine surgeons. Furthermore, this suggests that the current method by which patient satisfaction is being assessed and publicly reported may not necessarily correlate with validated measures that are used within the spine surgery setting to assess surgical efficacy.

ABBREVIATIONS

CG-CAHPS = Clinician and Group Consumer Assessment of Healthcare Providers and Systems; OPR = overall provider rating; PROM = patient-reported outcome measure; PROMIS-GH = Patient-Reported Outcomes Measurement Information System Global Health; PROMIS-GH-MH = PROMIS-GH Mental Health subscore; PROMIS-GH-PH = PROMIS-GH Physical Health subscore; VAS-BP = visual analog scale for back pain.

OBJECTIVE

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey was developed by the Centers for Medicare and Medicaid Services as a result of their value-based purchasing initiative. It allows patients to rate their experience with their provider in the outpatient setting. This presents a unique situation in healthcare in which the patient experience drives the marketplace, and since its creation, providers have sought to improve patient satisfaction. Within the spine surgery setting, however, the question remains whether improved patient satisfaction correlates with improved outcomes.

METHODS

All patients who had undergone lumbar spine surgery between 2009 and 2017 and who completed a CG-CAHPS survey after their procedure were studied. Demographic and surgical characteristics were then obtained. The primary outcomes of this study include patient-reported health outcomes measures such as the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) surveys for both mental health (PROMIS-GH-MH) and physical health (PROMIS-GH-PH), and the visual analog scale for back pain (VAS-BP). A multivariable linear regression analysis was used to assess whether patient satisfaction with their provider was associated with changes in each health status measure after adjusting for potential confounders.

RESULTS

The study population included 647 patients who had undergone lumbar spine surgery. Of these, 564 (87%) indicated that they were satisfied with the care they received. Demographic and surgical characteristics were largely similar between the two groups. Multivariable linear regression demonstrated that patient satisfaction with their provider was not a significant predictor of change in two of the three patient-reported outcomes (PROMIS-GH-MH and PROMIS-GH-PH) assessed at 1 year. However, top-box patient satisfaction with their provider was a significant predictor of improvement in VAS-BP scores at 1 year.

CONCLUSIONS

The authors found that after adjusting for patient-level covariates such as age, diagnosis of disc displacement, self-reported mental health, self-reported overall health, and preoperative patient-reported outcome measure status, a significant association was observed between top-box overall provider rating and 1-year improvement in VAS-BP, but no such association was observed for PROMIS-GH-PH and PROMIS-GH-MH. This suggests that pain-related outcome measures may serve as better predictors of patients’ satisfaction with their spine surgeons. Furthermore, this suggests that the current method by which patient satisfaction is being assessed and publicly reported may not necessarily correlate with validated measures that are used within the spine surgery setting to assess surgical efficacy.

In Brief

In the present study the authors looked at the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, which allows patients to rate their experience in the outpatient setting, and determined if there is an association between high patient satisfaction and some of the other measures spine surgeons use to determine surgical quality. Due to the public reporting of Clinician and Group Consumer Assessment of Healthcare Providers and Systems scores, it is important to determine their ability to predict surgical quality.

The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey allows patients to rate their experience with their provider in the outpatient setting by asking questions pertaining to 5 dimensions of care: access to care, provider communication, coordination of care, office staff, and overall provider rating (OPR). The survey was developed initially by the CAHPS consortium, and its purpose is 3-fold: 1) to enable providers to assess, understand, and improve upon the experience they provide to patients; 2) to measure provider performance for incentive payments; and 3) to allow patients to make informed decisions when choosing healthcare providers and medical groups.1 In order to achieve these aims, individual provider scores are reported in aggregate and made publicly available on hospital websites and within the Agency for Healthcare Quality and Research CAHPS database.2

Since their inception and incorporation into the Centers for Medicare and Medicaid Services reimbursement models, patient experience surveys have influenced the healthcare marketplace and incentivized healthcare systems to place an increasing emphasis on improving the patient experience.3,4 In general, this has been well received as a positive step toward providing high-quality, patient-centered care; across medical specialties, providers have improved the quality of care they deliver as the patient’s perspective on care is elicited.5–8 However, recent studies across various surgical specialties have suggested that patient satisfaction is independent of many of the validated process measures used to define surgical quality, including safety culture, complications, and readmissions.9–11

The quality of care delivered by spine surgeons has traditionally been approximated by a patient’s change in quality of life postoperatively, as assessed by a number of patient-reported outcome measures (PROMs).12,13 The recent introduction of patient experience as a quality metric is seen as progress, because patients previously had limited information about other patients’ experiences with a given provider. However, the question remains whether a higher patient rating of their spine surgeon postoperatively correlates with greater surgical quality, as measured by improvement in PROMs.14–16 For this reason, we sought to evaluate whether a top-box OPR on the postoperative CG-CAHPS survey, which measures patient satisfaction with an individual provider, is associated with improvements in PROMs.

Methods

This study is a retrospective review of patients who received lumbar spine surgery at a large academic medical center between 2009 and 2017. Study approval was obtained from the institutional review board at the Cleveland Clinic Foundation. The patient experience database at our institution was used to query CG-CAHPS survey responses by using International Classification of Diseases, Ninth Revision (ICD-9) codes. Next, baseline demographic and surgical characteristics were obtained for each patient through retrospective chart review. This study included patients who were 18 years of age or older by virtue of the fact that the CG-CAHPS survey is administered to a random sample of adult patients. Exclusion criteria included a diagnosis of scoliosis or spinal malignancy. Those who did not have 1-year follow-up were excluded from the final regression analysis. We determined the minimum sample size needed to find a difference between groups by using a power analysis. Using an effect size of 0.10 and a power of 0.95, it was determined that our final study population needed to include at least 132 participants in the final linear regression. A flowchart describing inclusion and exclusion criteria for our study is shown in Fig. 1.

FIG. 1.
FIG. 1.

Flowchart describing the determination of the final study population. Figure is available in color online only.

Patients’ overall satisfaction with their spine surgeon was determined using the OPR score on the CG-CAHPS survey. OPR is measured by the CG-CAHPS survey on a 0–10 scale, where 0 is “the worst” and 10 is “the best” possible provider rating. An OPR of 9 or 10 is considered a top-box response.17 Patients who selected a top-box response comprised our satisfied cohort. The remaining patients who selected 0–8 for an OPR comprised our unsatisfied cohort.

Survey response time was defined as the time between receipt of the CG-CAHPS survey and completion. Furthermore, the mean time between date of surgery and survey completion was 277 days. All CG-CAHPS surveys were collected postoperatively in order to capture a patient’s postoperative impression of their overall rating of the provider. Additionally, baseline patient characteristics (age, sex, race, body mass index, tobacco use, narcotic use, and comorbidities) and surgical characteristics (procedure type, diagnosis, and length of stay) were collected through retrospective chart review. Patient ratings of their overall health status and mental health status, ranging from “poor” to “excellent,” were collected from the CG-CAHPS survey.

PROMs served as the primary outcome measures of interest for this study, including the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) questionnaire’s Physical Health (PROMIS-GH-PH) and Mental Health (PROMIS-GH-MH) subscores and the visual analog scale for back pain (VAS-BP). PROMIS-GH-PH and PROMIS-GH-MH assess a patient’s physical and mental function across multiple domains and report an aggregate scaled score in comparison to a validated reference population, with a mean score of 50 and a standard deviation of 10.18 The VAS-BP is scored from 0 to 10, where 0 indicates no pain and 10 indicates the worst imaginable pain.19 These PROMs were collected at baseline and the 1-year postoperative follow-up. The mean time between surgery and acquisition of 1-year PROMs was 352 days. For each patient, the changes in PROMIS-GH, PROMIS-MH, and VAS-BP scores from baseline to the 1-year postoperative follow-up were subsequently computed. Positive changes in PROMIS-GH-MH and PROMIS-GH-PH suggest improvement, whereas negative changes in VAS-BP suggest improvement. Multivariable linear regression models were constructed to determine the association between overall satisfaction and baseline to 1-year postoperative changes in each PROM, adjusted for potential confounders.

All statistical analysis was conducted using IBM SPSS Statistics version 26.0 (IBM Corp.). Patient and surgical characteristics between satisfied and unsatisfied cohorts were compared using the Student t-test for continuous variables and chi-square test for categorical variables. The association between overall satisfaction and change in each PROM was first determined via simple unadjusted linear regression, and subsequently via multivariable linear regression models that adjusted for baseline patient and surgical characteristics. Multivariable linear regression models were adjusted for baseline and surgical characteristics with p values < 0.10 on univariate analysis. Preoperative PROMs were also included in the model to adjust for differences in preoperative health ratings. All p values < 0.05 were considered statistically significant.

Results

Our sample included 647 patients who had undergone lumbar spine surgery. Of these patients, 564 (87%) selected an OPR of either 9 or 10 on the CG-CAHPS survey and were included in the satisfied group. Patient characteristics were largely similar between our two groups (Tables 1 and 2). However, unsatisfied patients were more likely to be younger (65.28 ± 10.61 vs 60.58 ± 15.04 years, p < 0.001), to have a lower self-rating of their mental health (p < 0.001), and to have a lower self-rating of their overall health (p = 0.003) (Table 1). Preoperative VAS-BP scores (6.55 ± 2.13 vs 6.72 ± 1.93, p = 0.554) were similar between the two groups. Unsatisfied patients were more likely to have significantly lower preoperative PROMIS-GH-MH (46.99 ± 9.05 vs 42.00 ± 8.72, p = 0.002) and PROMIS-GH-PH (37.41 ± 6.16 vs 34.81 ± 5.43, p = 0.018) compared to satisfied patients (Table 3).

TABLE 1.

Characteristics of 647 patients who underwent lumbar spine surgery

CharacteristicSatisfiedNot Satisfiedp Value
No. of patients56483
Mean age, yrs65.28 ± 10.6160.58 ± 15.04<0.001
Sex0.360
 Male50.2%55.7%
 Female49.8%44.3%
Mean BMI30.32 ± 6.0330.35 ± 6.580.965
Caucasian ethnicity94.9%97.4%0.327
Tobacco smoker48.0%47.0%0.858
Previous narcotic use36.0%42.2%0.276
Mean CCI3.11 ± 3.493.12 ± 3.740.973
Primary diagnosis
 Disc displacement8.7%14.5%0.093
 Spinal stenosis59.9%54.2%0.323
 Degenerative disc disease1.1%0.0%0.345
 Spondylosis3.5%7.2%0.111
 Spondylolisthesis26.8%24.1%0.606
Overall health0.003
 Excellent6.3%0.0%
 Very good34.5%28.4%
 Good43.5%40.7%
 Fair/poor14.3%29.6%
 Poor1.4%1.2%
Mental health<0.001
 Excellent34.6%12.3%
 Very good35.3%39.5%
 Good23.9%32.1%
 Fair5.7%13.6%
 Poor0.5%2.5%
Survey response time6 (4–12)5 (4–10)0.152

BMI = body mass index; CCI = Charlson Comorbidity Index.

Mean values are presented ± SD. Survey response time is reported as the median (IQR) number of days. Boldface type indicates statistical significance. All p values < 0.05 were considered statistically significant.

TABLE 2.

Surgical characteristics of 647 patients who underwent lumbar spine surgery

CharacteristicSatisfiedNot Satisfiedp Value
No. of patients56483
Decompression73.4%80.7%0.154
Discectomy35.1%27.7%0.185
Fusion53.9%47.0%0.239
Length of stay3 (1.66–4.18)3 (1–3.5)0.113

Length of stay is reported as the median (IQR) number of days.

TABLE 3.

Health outcomes and satisfaction with physician

OutcomeSatisfiedNot Satisfiedp Value
PROMIS-GH-MH
 No. of available subjects27138
 Preop46.99 ± 9.0542.00 ± 8.720.002
 1-yr postop48.93 ± 9.6244.26 ± 8.650.005
 Δ1.94 ± 8.232.27 ± 8.320.817
PROMIS-GH-PH
 No. of available subjects26635
 Preop37.41 ± 6.1634.81 ± 5.430.018
 1-yr postop43.97 ± 8.2339.85 ± 7.140.005
 Δ6.56 ± 7.995.04 ± 6.290.280
VAS-BP
 No. of available subjects36258
 Preop6.55 ± 2.136.72 ± 1.930.554
 1-yr postop3.71 ± 2.535.93 ± 2.32<0.001
 Δ−2.85 ± 2.71−0.79 ± 2.41<0.001

Δ = change in preoperative to 1-year postoperative health status measure.

Values are presented as mean ± SD unless otherwise noted. Boldface type indicates statistical significance.

At the 1-year postoperative follow-up, there were no significant differences in the magnitude of improvement in PROMIS-GH-MH (1.94 ± 8.23 vs 2.27 ± 8.32, p = 0.817) and PROMIS-GH-PH (6.56 ± 7.99 vs 5.04 ± 6.29, p = 0.280) between the satisfied and unsatisfied groups. However, there was a significant difference in the magnitude of improvement in VAS-BP (−2.85 ± 2.71 vs −0.79 ± 2.41, p < 0.001) between the satisfied and unsatisfied groups at the 1-year postoperative follow-up (Table 3).

Multivariable linear regression demonstrated that top-box patient satisfaction with their spine surgeon was not a significant predictor of change in two of the three patient-reported outcomes assessed (PROMIS-GH-MH and PROMIS-GH-PH) at 1 year postoperatively. However, top-box patient satisfaction with their provider was a significant predictor of improvement in VAS-BP scores at 1 year (OR −1.77, 95% CI −2.40 to −1.14, R2 = 0.390) (Table 4).

TABLE 4.

Linear regression analysis of the association between satisfaction with physician and pre- to 1-year postoperative change in health status measures

ΔPROMIS-GH-PH Score (95% CI)ΔPROMIS-GH-MH Score (95% CI)ΔVAS-BP Score (95% CI)
VariableUnadjusted EstimateAdjusted Estimatep ValueUnadjusted EstimateAdjusted Estimatep ValueUnadjusted EstimateAdjusted Estimatep Value
Physician encounter1.52 (−1.25 to 4.29)1.75 (−0.58 to 4.08)0.140−0.33 (−3.14 to 2.48)0.40 (−1.75 to 2.56)0.713−2.05 (−2.80 to −1.31)−1.77 (−2.40 to −1.14)<0.001
Age0.02 (−0.05 to 0.09)0.5490.04 (−0.03 to 0.11)0.250−0.01 (−0.03 to 0.01)0.519
Disc displacement diagnosis−2.33 (−5.20 to 0.55)0.1120.12 (−2.54 to 2.77)0.9300.65 (−0.18 to 1.48)0.126
Overall health3.76 (2.73 to 4.80)<0.0012.42 (1.48 to 3.37)<0.001−1.03 (−1.35 to −0.72)<0.001
Mental health1.28 (0.35 to 2.21)0.0074.20 (3.18 to 5.21)<0.001−0.18 (−0.46 to 0.10)0.209
Preop−0.71 (−0.84 to −0.58)<0.001−0.70 (−0.79 to −0.60)<0.001−0.75 (−0.86 to −0.65)<0.001

Boldface type indicates statistical significance. Preoperative pertains to the last row; all other data were obtained 1 year postoperatively.

The models also revealed that there were several other predictors of postoperative changes in our patient-reported health status measures. An increase by 1 unit in self-reported mental health caused a 1.28-unit (95% CI 0.35–2.21, R2 = 0.341) increase in PROMIS-GH-PH improvement at the 1-year postoperative follow-up. Furthermore, an increase by 1 unit in self-reported overall health caused a 3.76-unit (95% CI 2.73–4.80, R2 = 0.341) increase in PROMIS-GH-PH improvement at the 1-year postoperative follow-up (Table 4).

Furthermore, an increase by 1 unit in self-reported mental health caused a 4.20-unit (95% CI 3.18–5.21, R2 = 0.455) increase in PROMIS-GH-MH improvement at the 1-year postoperative follow-up. Additionally, an increase by 1 unit in self-reported overall health caused a 2.42-unit (95% CI 1.48–3.37, R2 = 0.455) increase in PROMIS-GH-MH at the 1-year postoperative follow-up. A 1-unit increase in self-reported overall health also caused a 1.03-unit (95% CI 1.35–0.72, R2 = 0.390) increase in VAS-BP improvement at the 1-year postoperative follow-up (Table 4).

An increase in preoperative PROMIS-GH-PH and PROMIS-GH-MH scores by 1 unit (indicating greater preoperative health status) resulted in 0.71-unit (95% CI 0.84–0.58, R2 = 0.341) and 0.70-unit (95% CI 0.79–0.60, R2 = 0.455) decreases in PROMIS-GH-PH and PROMIS-GH-MH improvement, respectively, at the 1-year postoperative follow-up. An increase in preoperative VAS-BP scores by 1 unit (indicating worse preoperative health status) resulted in a 0.75-unit (95% CI 0.86–0.65, R2 = 0.390) increase in VAS-BP improvement at the 1-year postoperative follow-up (Table 4).

Discussion

As patient experience scores become publicly available, patient ratings of providers inform the decisions made by other patients when searching for new healthcare providers and medical groups. Specifically, in this study the authors sought to answer the following question: is there an association between a top-box OPR on the CG-CAHPS survey and improvements in a number of patient-reported outcomes? We found that after adjusting for patient-level covariates such as age, diagnosis of disc displacement, self-reported mental health, self-reported overall health, and preoperative PROM status, there was no association between a top-box OPR and 1-year improvements in two of the three PROMs looked at in this study. There was, however, a significant association between improvements in VAS-BP 1 year postoperatively and increases in patient satisfaction.

It is important to note that the present work is not intended to diminish the significance of patient experience. However, our data suggest that patients’ postoperative overall rating of their spine surgeon does not correlate with two patient-reported functional outcome measures that are commonly used by surgeons to evaluate the efficacy of a surgical intervention. This finding is generally concordant with previous work that showed no association of inpatient experience scores after spine surgery with PROMs at the 1-year postoperative follow-up.16 This finding may be reasonably explained by the fact that the CG-CAHPS survey was not designed to be predictive of changes in the PROMs used in the spine surgery setting; rather, its initial intention was to allow patients to rate their experience based on factors unrelated to their surgical care or their change in functional outcome. Thus, one may not expect an association between the two, and those patients who indicated that they were unsatisfied with their care may in fact have experienced substantial improvement in their functional outcomes, and vice versa. The issue this poses, however, is that satisfaction scores are reported publicly. Thus, the patient perception of care is the only measure seen by future patients, without any surgical quality data to accompany it.

One PROM whose change at 1 year did have an association with a top-box OPR was VAS-BP. There was a significant association between providing a top-box provider rating and reductions in VAS-BP scores at 1 year, indicating improvement. Within our cohort, patients who experienced a reduction in back pain were therefore more likely to indicate satisfaction with their spine surgeons. This finding is unsurprising given the fact that back pain is often a major indication for spine surgery, and suggests that pain-related outcome measures may serve as better predictors of patient satisfaction with their spine surgeons than outcome measures assessing global health status.

Although PROMs may provide a more desirable indicator of quality in spine surgery, these metrics are also not immune to influence from factors unrelated to the quality of the surgical care delivered. Our model demonstrated that after adjusting for patient-level covariates, worse self-reported mental health was associated with less improvement in PROMIS-GH-PH, PROMIS-GH-MH, and VAS-BP at 1 year postoperatively. This finding is in agreement with prior work studying the association between mental health and patient-reported outcomes. Chapin et al.20 showed that patients who self-reported poor mental health, specifically depression, experienced worse patient-reported outcomes at all time points analyzed (preoperatively, 3 months postoperatively, and 12 months postoperatively). Furthermore, Celestin et al.21 conducted a systematic review that aimed to identify predictors of treatment outcomes in the lumbar spine surgery population. In that review, the authors demonstrated that 92% of the studies identified found an association between psychological factors such as depression and poor outcomes after lumbar surgery.

Our study also found that better preoperative PROMIS-GH-PH, PROMIS-GH-MH, and VAS-BP scores were all independent predictors of decreased improvements in 1-year postoperative PROMIS-GH-PH, PROMIS-GH-MH, and VAS-BP scores. This finding is intuitive, because a patient with a better preoperative score has a smaller opportunity to improve postoperatively than a patient who reports a worse score. It is also consistent with previous literature analyzing PROMs both pre- and postoperatively.22,23 Numerous other studies have also discussed the idea of response shift, whereby individuals can change their appraisal of the same PROM survey item over time.24 In the context of the present study, this would suggest that as patients’ functional status changes after surgery, their conceptualization of quality of life changes, as do their internal standards of what indicates good versus poor quality of life. This influences PROM scores and thus makes it difficult to assess progression of functional status and quality of life following surgery based on these measures alone. Despite these limitations in PROMs, their ability to elicit the patient perception of their improvement, rather than the patient perception of the quality of care they received, currently makes them valuable clinical tools to gauge patient improvement in functional status following spine surgery.

A need exists for a better way to determine the quality of care delivered in the spine surgery setting. Despite the use of patient satisfaction as the primary method by which the general public provides information about the quality of care delivered, no one measure, or type of measurement, is likely to be adequate to define the outcome of surgery. Spine surgeons and patients alike should strive to integrate PROMs with patient satisfaction scores when evaluating the quality of care delivered and received. Furthermore, given the concerns about the subjectivity of patient experience and patient-reported outcomes, objective outcome measures based on biophysical changes may be welcomed by both patients and physicians. Previous work has studied electromyogram activity, spine mobility, and straight leg raise results with differing associations with pain severity or functional status.25–27 Continued pursuit of new objective measures is essential because the integration of patient perception of care, evaluation of change in health status, and change in objective performance is likely to be a large step toward accurately measuring the quality of care delivered.

The present study is not without limitations. The generalizability of the findings may be limited due to the study being conducted at a tertiary medical center. Furthermore, the relatively short follow-up period accompanied by the incompleteness of 1-year follow-up data limited our study population. Moreover, in order to ensure an adequate sample size, patients included in this study did not necessarily complete postoperative CG-CAHPS surveys on the same date that PROMs were obtained. However, CG-CAHPS survey completion and PROM acquisition for our cohort occurred, on average, during a similar time frame (277 days vs 352 days postoperatively, respectively). Selection and dropout bias are also possible limitations to this study, because survey nonresponders may have different characteristics from survey responders. This may cause our cohorts to differ from the general population in unobservable ways, and we were unable to examine patient characteristics and PROMs for survey nonresponders in this study. However, both CG-CAHPS and PROMs are collected prospectively, with CG-CAHPS surveys also being administered randomly, providing a more representative sample of the total patient population seen by providers.

Conclusions

With PROMs being one of the primary methods by which spine surgeons determine the quality of care delivered, and patient experience scores being one of the primary ways by which the public determines the quality of care delivered by an individual provider, we aimed to understand whether indicating satisfaction with spine surgeons on the CG-CAHPS survey is associated with improvements in PROMs. We found that after adjusting for patient-level covariates such as age, diagnosis of disc displacement, self-reported mental health, and preoperative PROM status, there was no association between a top-box OPR and 1-year improvements in PROMIS-GH-PH and PROMIS-GH-MH. However, a significant association was observed between a top-box OPR and VAS-BP, suggesting that pain-related outcome measures may have a stronger influence on patient satisfaction than measures of global health status. Our results suggest that the current method by which patient satisfaction with an individual provider is being assessed and publicly reported may not necessarily correlate with the validated measures that are used within the spine surgery setting to assess surgical efficacy. Therefore, an effort should be made to publicly report PROMs in addition to patient satisfaction scores, and future work should assess the efficacy of using both measures to gauge the quality of care delivered.

Disclosures

Dr. Mroz receives royalties from Stryker ($1,150,000). Dr. Steinmetz receives royalties from Zimmer/Biomet ($9000/year) and Elsevier ($3000/year); is a consultant for Globus ($5000/year); and receives honoraria from Globus ($9000) and Stryker ($7500).

Author Contributions

Conception and design: Rabah, Levin, Winkelman, Mroz, Steinmetz. Acquisition of data: Rabah, Levin, Winkelman. Analysis and interpretation of data: Rabah, Khan, Winkelman. Drafting the article: Rabah, Khan, Winkelman. Critically revising the article: Rabah, Khan, Winkelman, Mroz, Steinmetz. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Rabah. Statistical analysis: Rabah. Administrative/technical/material support: Rabah, Mroz, Steinmetz. Study supervision: Rabah, Mroz, Steinmetz.

Supplemental Information

Previous Presentations

The abstract of this manuscript was presented at the 2019 Annual Meeting of the Congress of Neurological Surgeons, San Francisco, CA, October 19–23, 2019.

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    Chotai S, Sivaganesan A, Parker SL, et al. Patient-specific factors associated with dissatisfaction after elective surgery for degenerative spine diseases. Neurosurgery. 2015;77(2):157163.

    • Search Google Scholar
    • Export Citation
  • 16

    Levin JM, Winkelman RD, Smith GA, et al. The association between the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and real-world clinical outcomes in lumbar spine surgery. Spine J. 2017;17(11):15861593.

    • Search Google Scholar
    • Export Citation
  • 17

    Agency for Healthcare Research and Quality. The CAHPS Clinician & Group Survey Database: How Results are Calculated. Centers for Medicare and Medicaid Services; 2017. Accessed August 26, 2020. https://cahpsdatabase.ahrq.gov/cahpsidb/Public/Files/Doc6_How_Results_are_Calculated_CG_2016.pdf

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    • Export Citation
  • 18

    Gershon RC, Rothrock N, Hanrahan R, et al. The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas. 2010;11(3):304314.

    • Search Google Scholar
    • Export Citation
  • 19

    Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990;13(4):227236.

    • Search Google Scholar
    • Export Citation
  • 20

    Chapin L, Ward K, Ryken T. Preoperative depression, smoking, and employment status are significant factors in patient satisfaction after lumbar spine surgery. Clin Spine Surg. 2017;30(6):E725E732.

    • Search Google Scholar
    • Export Citation
  • 21

    Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis. Pain Med. 2009;10(4):639653.

    • Search Google Scholar
    • Export Citation
  • 22

    Maillard J, Elia N, Haller CS, et al. Preoperative and early postoperative quality of life after major surgery—a prospective observational study. Health Qual Life Outcomes. 2015;13:12.

    • Search Google Scholar
    • Export Citation
  • 23

    Tripp DA, Abraham E, Lambert M, et al. Biopsychosocial factors predict quality of life in thoracolumbar spine surgery. Qual Life Res. 26(11):30993110.

    • Search Google Scholar
    • Export Citation
  • 24

    Rapkin BD, Garcia I, Michael W, et al. Distinguishing appraisal and personality influences on quality of life in chronic illness: introducing the Quality-of-Life Appraisal Profile version 2. Qual Life Res. 2017;26(10):28152829.

    • Search Google Scholar
    • Export Citation
  • 25

    Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine (Phila Pa 1976). 2000;25(24):31003103.

    • Search Google Scholar
    • Export Citation
  • 26

    Mannion AF, Dvorak J, Müntener M, Grob D. A prospective study of the interrelationship between subjective and objective measures of disability before and 2 months after lumbar decompression surgery for disc herniation. Eur Spine J. 2005;14(5):454465.

    • Search Google Scholar
    • Export Citation
  • 27

    Panagopoulos J, Hush J, Steffens D, Hancock MJ. Do MRI findings change over a period of up to 1 year in patients with low back pain and/or sciatica?: a systematic review. Spine (Phila Pa 1976). 2017;42(7):504512.

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Images showing severe global coronal malalignment preoperatively and after correction using posterior instrumentation and a kickstand rod on the side of coronal malalignment. See the article by Buell et al. (pp 399–412).

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    Flowchart describing the determination of the final study population. Figure is available in color online only.

  • 1

    Development of the CAHPS Clinician and Group Survey. Agency for Healthcare Research and Quality. February 2018. Accessed January 30, 2020. https://www.ahrq.gov/cahps/surveys-guidance/cg/about/Develop-CG-Surveys.html

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  • 2

    Physician Compare datasets. Data.Medicare.gov. Accessed August 25, 2020. https://data.medicare.gov/data/physician-compare

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    Elliott MN, Cohea CW, Lehrman WG, et al. Accelerating improvement and narrowing gaps: trends in patients’ experiences with hospital care reflected in HCAHPS public reporting. Health Serv Res. 2015;50(6):18501867.

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    Elliot MN, Lehrman WG, Goldstein EH, et al. Hospital survey shows improvements in patient experience. Health Aff (Millwood). 2010;29(11):20612067.

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    Glickman SW, Boulding W, Manary M, et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;3(2):188195.

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    Kane RL, Maciejewski M, Finch M. The relationship of patient satisfaction with care and clinical outcomes. Med Care. 1997;35(7):714730.

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    Tevis SE, Kennedy GD, Kent KC. Is there a relationship between patient satisfaction and favorable surgical outcomes? Adv Surg. 2015;49(1):221233.

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    Lyu H, Wick EC, Housman M, et al. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362367.

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    Kennedy GD, Tevis SE, Kent KC. Is there a relationship between patient satisfaction and favorable outcomes? Ann Surg. 2014;260(4):592600.

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  • 12

    Sharma M, Ugiliweneza B, Beswick J, Boakye M. Concurrent validity and comparative responsiveness of PROMIS-SF versus legacy measures in the cervical and lumbar spine population: longitudinal analysis from baseline to postsurgery. World Neurosurg. 2018;115:e664e675.

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  • 13

    Hung M, Hon SD, Franklin JD, et al. Psychometric properties of the PROMIS physical function item bank in patients with spinal disorders. Spine (Phila Pa 1976). 2014;39(2):158163.

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  • 14

    Godil SS, Parker SL, Zuckerman SL, et al. Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy. Spine J. 2013;13(9):10061012.

    • Search Google Scholar
    • Export Citation
  • 15

    Chotai S, Sivaganesan A, Parker SL, et al. Patient-specific factors associated with dissatisfaction after elective surgery for degenerative spine diseases. Neurosurgery. 2015;77(2):157163.

    • Search Google Scholar
    • Export Citation
  • 16

    Levin JM, Winkelman RD, Smith GA, et al. The association between the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and real-world clinical outcomes in lumbar spine surgery. Spine J. 2017;17(11):15861593.

    • Search Google Scholar
    • Export Citation
  • 17

    Agency for Healthcare Research and Quality. The CAHPS Clinician & Group Survey Database: How Results are Calculated. Centers for Medicare and Medicaid Services; 2017. Accessed August 26, 2020. https://cahpsdatabase.ahrq.gov/cahpsidb/Public/Files/Doc6_How_Results_are_Calculated_CG_2016.pdf

    • Search Google Scholar
    • Export Citation
  • 18

    Gershon RC, Rothrock N, Hanrahan R, et al. The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas. 2010;11(3):304314.

    • Search Google Scholar
    • Export Citation
  • 19

    Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990;13(4):227236.

    • Search Google Scholar
    • Export Citation
  • 20

    Chapin L, Ward K, Ryken T. Preoperative depression, smoking, and employment status are significant factors in patient satisfaction after lumbar spine surgery. Clin Spine Surg. 2017;30(6):E725E732.

    • Search Google Scholar
    • Export Citation
  • 21

    Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis. Pain Med. 2009;10(4):639653.

    • Search Google Scholar
    • Export Citation
  • 22

    Maillard J, Elia N, Haller CS, et al. Preoperative and early postoperative quality of life after major surgery—a prospective observational study. Health Qual Life Outcomes. 2015;13:12.

    • Search Google Scholar
    • Export Citation
  • 23

    Tripp DA, Abraham E, Lambert M, et al. Biopsychosocial factors predict quality of life in thoracolumbar spine surgery. Qual Life Res. 26(11):30993110.

    • Search Google Scholar
    • Export Citation
  • 24

    Rapkin BD, Garcia I, Michael W, et al. Distinguishing appraisal and personality influences on quality of life in chronic illness: introducing the Quality-of-Life Appraisal Profile version 2. Qual Life Res. 2017;26(10):28152829.

    • Search Google Scholar
    • Export Citation
  • 25

    Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine (Phila Pa 1976). 2000;25(24):31003103.

    • Search Google Scholar
    • Export Citation
  • 26

    Mannion AF, Dvorak J, Müntener M, Grob D. A prospective study of the interrelationship between subjective and objective measures of disability before and 2 months after lumbar decompression surgery for disc herniation. Eur Spine J. 2005;14(5):454465.

    • Search Google Scholar
    • Export Citation
  • 27

    Panagopoulos J, Hush J, Steffens D, Hancock MJ. Do MRI findings change over a period of up to 1 year in patients with low back pain and/or sciatica?: a systematic review. Spine (Phila Pa 1976). 2017;42(7):504512.

    • Search Google Scholar
    • Export Citation

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