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Patient Satisfaction: An Emerging Health Policy Issue

What the orthopaedic surgeon needs to know

Brent J. Morris, MD; Alex A. Jahangir, MD; and Manish K. Sethi, MD

The need to improve quality in healthcare delivery is increasing. The Centers for Medicare & Medicaid Services (CMS), hospitals, and insurance providers alike are striving to better define and measure quality of health care. A major component of quality of health care is patient satisfaction. Furthermore, patient satisfaction is critical to how well patients do; research has identified a clear link between patient outcomes and patient satisfaction scores.

Patient satisfaction is a key determinant of quality of care and an important component of pay-for-performance metrics. Under the CMS Hospital Inpatient Value-Based Purchasing (HIVBP) program, Medicare reimbursements are linked to patient satisfaction and surveys completed by patients. Beginning this year (2013), CMS will make value-based incentive payments to acute care hospitals based, in part, on the results of patient satisfaction surveys completed by patients discharged on or after October 1, 2012.

It is therefore critical that orthopaedic surgeons better understand this vital and complex issue.


Patient-physician communication is key in improving patient satisfaction.
Courtesy of iStockphoto\Thinkstock

What is patient satisfaction?
Patient satisfaction is multifaceted and a very challenging outcome to define. Patient expectations of care and attitudes greatly contribute to satisfaction; other psychosocial factors, including pain and depression, are also known to contribute to patient satisfaction scores. Historically, physicians, especially surgeons, have focused on surgical technique and objective outcomes as measures of “patient satisfaction,” while patients place great value on the surgeon-patient interaction.

Why does it matter?
The CMS HIVBP program uses the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to assess patient satisfaction in Medicare patients after an inpatient hospitalization. HCAHPS is the first national, standardized, and publicly reported survey of patients’ perspectives of hospital care. The HCAHPS survey has a specific domain evaluating patient satisfaction regarding “Doctor Communication.” Three of the 25 survey questions specifically assess patient satisfaction with doctor communication, as follows (words in italics are underscored in the survey itself):

  • During this hospital stay, how often did doctors treat you with courtesy and respect?
  • During this hospital stay, how often did doctors listen carefully to you?
  • During this hospital stay, how often did doctors explain things in a way you could understand?

For each question, patients have the option of answering “never,” “sometimes,” “usually,” or “always. Responses to the doctor communication domain of the HCAHPS survey contribute to the physician’s evaluation, the overall patient satisfaction score, and, ultimately, the hospital’s reimbursement.

Improving patient-physician communication
Patient-physician communication has been shown to be key in improving patient satisfaction. Patient-physician communication can be challenging, but presents a tremendous opportunity for improvement.

Studies have found that, when asked to identify the physician in charge of their care at the time of discharge, up to 90 percent of medical inpatients are unable to correctly name their treating physician. The orthopaedic patient population is even more challenging due to the number of patients with traumatic injuries who receive inpatient surgery in the acute setting, compared to those who receive elective surgeries or medical admissions. Many orthopaedic patients are admitted to hospitals directly from the emergency department (ED), and hospital admission from the ED has been associated with a decreased ability of patients to identify their treating physicians.

The acuity of some orthopaedic injuries does not always permit patients and surgeons to establish a strong patient-physician relationship prior to surgery. Even in these settings, however, appropriate preoperative discussions are necessary to address the patient’s concerns and priorities, due to the distinct differences that exist between patients and surgeons regarding expectations and outcomes. Ultimately, when patient expectations are met, patients are more satisfied and have better outcomes.

Improving patient satisfaction
The Vanderbilt Orthopaedic Institute Center for Health Policy is currently working to enhance patient satisfaction in the orthopaedic trauma patient population by using biosketch cards to improve patient recognition of the attending surgeon. Early results of the study show improved physician recognition and increased patient satisfaction scores, even in this challenging population.

Managing patient expectations and psychosocial factors, such as pain and depression, that can drive patient satisfaction can be difficult. Individualizing patient preoperative counseling and shared decision-making can help to identify patient-specific factors, such as chronic pain and depression, that may negatively impact patient satisfaction scores. By setting appropriate preoperative expectations and managing pain and depression, physicians can help patients achieve good outcomes.

Conclusions
In an era in which physicians will be increasingly measured by the outcomes of their treatments, it is critical that orthopaedic surgeons better understand the issue of patient satisfaction. Additional research on ways to improve patient satisfaction is needed.

Brent J. Morris, MD; Alex A. Jahangir, MD; and Manish K. Sethi, MD, are all associated with the Vanderbilt Orthopaedic Institute Center for Health Policy.

Bottom Line

  • Patient satisfaction is a driver of patient outcomes and an important component of pay-for-performance metrics.
  • Improving patient-physician communication will improve patient satisfaction.
  • More research is needed to continue to better define and improve patient satisfaction.

References

  1. Hospital Inpatient Value-Based Purchasing Program [Centers for Medicare & Medicaid Services web site]. Available at: http://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10568.pdf. Accessed April 13, 2013.
  2. O’Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ, LEAP Study Group: Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Joint Surg Am 2008;90(6):1206-1211. http://www.ncbi.nlm.nih.gov/pubmed/18519312
  3. Thompson AG, Suñol R: Expectations as determinants of patient satisfaction: Concepts, theory and evidence. Int J Qual Health Care. 1995;7(2):127-141.
  4. Lozano Calderón SA, Paiva A, Ring D: Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg Am 2008;33(3):303-307.
  5. Archer KR, Castillo RC, Wegener ST, Abraham CM, Obremskey WT: Pain and satisfaction in hospitalized trauma patients: The importance of self-efficacy and psychological distress. J Trauma Acute Care Surg 2012;72(4):1068-1077.
  6. Harris IA, Dao AT, Young JM, Solomon MJ, Jalaludin BB: Predictors of patient and surgeon satisfaction after orthopaedic trauma. Injury 2009;40(4):377-384.
  7. Bozic KJ, Kaufman D, Chan VC, Caminiti S, Lewis C: Factors that influence provider selection for elective total joint arthroplasty. Clin Orthop Relat Res 2012; Epub ahead of print.
  8. Centers for Medicare &Medicaid Services [Hospital Care Quality Information from the Consumer Perspective Web site]. Available at: http://www.hcahpsonline.org. Accessed November 16, 2012.
  9. Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S: The effects of physician communications skills on patient satisfaction; recall, and adherence. J Chronic Dis 1984;37(9):755-764.
  10. Chang JT, Hays RD, Shekelle PG, et al: Patients' global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med 2006;144(9):665-672.
  11. Olson DP, Windish DM: Communication discrepancies between physicians and hospitalized patients. Arch Intern Med 2010;170(15):1302-1307.
  12. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D: Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med 2009;169(2):199-201.
  13. Bullens PH, van Loon CJ, de Waal Malefijt MC, Laan RF, Veth RP: Patient satisfaction after total knee arthroplasty: A comparison between subjective and objective outcome assessments. J Arthroplasty 2001;16(6):740-747.
  14. Sinikallio S, Aalto T, Airaksinen O, et al: Depression is associated with poorer outcome of lumbar spinal stenosis surgery. Eur Spine J 2007;16(7):905-912.

AAOS Now
June 2013 Issue
http://www.aaos.org/news/aaosnow/jun13/advocacy5.asp