Predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery

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OBJECTIVE

As compensation transitions from a fee-for-service to pay-for-performance healthcare model, providers must prioritize patient-centered experiences. Here, the authors’ primary aim was to identify predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery.

METHODS

The Michigan Spine Surgery Improvement Collaborative (MSSIC) was queried for all lumbar operations at the 1- and 2-year follow-ups. Predictors of patients’ postoperative contentment were identified per the North American Spine Surgery (NASS) Patient Satisfaction Index, wherein satisfied patients were assigned a score of 1 (“the treatment met my expectations”) or 2 (“I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome”) and unsatisfied patients were assigned a score of 3 (“I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome”) or 4 (“I am the same or worse than before treatment”). Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios (RRadj).

RESULTS

Among 5390 patients with a 1-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by higher body mass index (RRadj =1.07, p < 0.001), African American race compared to white (RRadj = 1.51, p < 0.001), education level less than high school graduation compared to a high school diploma or equivalent (RRadj = 1.25, p = 0.008), smoking (RRadj = 1.34, p < 0.001), daily preoperative opioid use > 6 months (RRadj = 1.22, p < 0.001), depression (RRadj = 1.31, p < 0.001), symptom duration > 1 year (RRadj = 1.32, p < 0.001), previous spine surgery (RRadj = 1.32, p < 0.001), and higher baseline numeric rating scale (NRS)–back pain score (RRadj = 1.04, p = 0.002). Conversely, an education level higher than high school graduation, independent ambulation (RRadj = 0.90, p = 0.039), higher baseline NRS–leg pain score (RRadj = 0.97, p = 0.013), and fusion surgery (RRadj = 0.88, p = 0.014) decreased dissatisfaction.

Among 2776 patients with a 2-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by a non-white race, current smoking (RRadj = 1.26, p = 0.004), depression (RRadj = 1.34, p < 0.001), symptom duration > 1 year (RRadj = 1.47, p < 0.001), previous spine surgery (RRadj = 1.28, p < 0.001), and higher baseline NRS–back pain score (RRadj = 1.06, p = 0.003). Conversely, at least some college education (RRadj = 0.87, p = 0.035) decreased the risk of dissatisfaction.

CONCLUSIONS

Both comorbid conditions and socioeconomic circumstances must be considered in counseling patients on postoperative expectations. After race, symptom duration was the strongest predictor of dissatisfaction; thus, patient-centered measures must be prioritized. These findings should serve as a tool for surgeons to identify at-risk populations that may need more attention regarding effective communication and additional preoperative counseling to address potential barriers unique to their situation.

ABBREVIATIONS ASA = American Society of Anesthesiologists; BCBSM = Blue Cross Blue Shield of Michigan; BCN = Blue Care Network; BMI = body mass index; GED = General Educational Development; GEE = generalized estimating equation; MCID = minimum clinically important difference; MSSIC = Michigan Spine Surgery Improvement Collaborative; NASS = North American Spine Society; NRS = numeric rating scale; ODI = Oswestry Disability Index; PHQ-2 = Patient Health Questionnaire–2; PRO = patient-reported outcome; PSI = Patient Satisfaction Index; RRadj = adjusted risk ratio; SSI = surgical site infection.
Article Information

Contributor Notes

Correspondence Victor Chang: Henry Ford Hospital, Detroit, MI. vchang1@hfhs.org.INCLUDE WHEN CITING Published online November 22, 2019; DOI: 10.3171/2019.8.SPINE19260.

M.M. and M.A.A. share first authorship.

Disclosures Dr. Chang receives research funding from Medtronic, who was not specifically involved in this project. He is also a consultant for Globus Medical, K2M, and SpineGuard. Dr. Park is a consultant for Globus, NuVasive, and Allosource and receives royalties from Globus. Although Blue Cross Blue Shield of Michigan (BCBSM) and MSSIC work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. Support for MSSIC is provided by BCBSM and Blue Care Network as part of the BCBSM Value Partnerships program.
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