The Spine Journal 16 (2016) 1290–1291

Commentary

The “patient experience”: a quality metric to be aware of Seba Ramhmdani, MDa,b, Ali Bydon, MDa,b,* a

The Spinal Column Biomechanics and Surgical Outcomes Laboratory, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-109, Baltimore, MD 21287, USA b Department of Neurosurgery, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-109, Baltimore, MD 21287, USA Received 7 June 2016; revised 12 July 2016; accepted 23 August 2016

COMMENTARY ON: Etier BE Jr, Orr SP, Antonetti J, Thomas SB, Theiss SM. Factors impacting Press Ganey patient satisfaction scores in orthopedic surgery spine clinic. Spine J 2016:16:1285–9. (in this issue).

Traditional clinical outcome measures, such as mortality and complication rates, have been shown to insufficiently reflect patients’ perspectives of the level and quality of care received. Quality of life assessment, for example, has been criticized for not being truly representative of patients’ experiences [1], whereas cost-effectiveness analyses serve to achieve the greatest health-care benefits based on healthcare costs. As such, patients’ experiences of the level of quality of care received remain muffled when one looks at traditional clinical and economic outcome measures. During the past two decades, health care in the United States has been progressively shifting toward a “consumerdirected industry,” focusing on translating patients’ experiences into scoring systems through designated questionnaires [2]. Patient satisfaction surveys are increasingly incorporated into clinical practices around the nation to guide the quality of health care provided and to measure physician performance [3]. The Press Ganey satisfaction questionnaire, approved by the Centers for Medicare & Medicaid Services, is currently being used by more than 26,000 health-care providers to quantify patient satisfaction scores, a metric that subsequently FDA device/drug status: Not applicable. Author disclosures: SR: Nothing to disclose. AB: Consulting: MedImmune (B), outside the submitted work; Grants: DePuy Spine (F), outside the submitted work. The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com. The authors have no personal, financial, or institutional interest in any of the materials described in this article. However, the authors report the following disclosures (unrelated to this article): Ali Bydon is the recipient of a research grant from DePuy Spine. He serves on the clinical advisory board of MedImmune, LLC. Seba Ramhmdani has nothing to disclose. * Corresponding author. The Johns Hopkins University School of Medicine, 600 North Wolfe St, Meyer 5-109, Baltimore, MD 21287, USA. Tel.: +1 (410) 955 4424; fax: +1 (410) 502-3399. E-mail address: [email protected] (A. Bydon) http://dx.doi.org/10.1016/j.spinee.2016.08.028 1529-9430/© 2016 Elsevier Inc. All rights reserved.

affects reimbursement and payout incentives [4]. In the near future, through the Merit-Based Incentive Payment System, payments to all clinicians (physicians, physician assistants, nurse practitioners) participating in Medicare plan B will be based on several quality measures, including patient satisfaction scores [5]. Hospitals’ remuneration will also be adjusted according to patients’ ratings through the Hospital Consumer Assessment of Healthcare Providers and Systems satisfaction questionnaire [6]. Thus, an imperative need to explore the factors that affect satisfaction scores has emerged, with the goal of improving “patient experience,” in both inpatient and outpatient settings. Importantly, a deeper understanding of patients’ viewpoints will help clinicians build rapport with their patients, establish patient loyalty, and eventually improve patient compliance with recommended treatment protocols [7]. In the manuscript by Etier et al. [8], the authors reviewed the Press Ganey survey used in an orthopedic spine surgery clinic to explore the factors that impact patient satisfaction. The authors randomly sampled a total of 352 patients using electronic and written surveys; data were collected over a 49-month period. The most common diagnosis was lumbar stenosis, and the least common diagnosis was myelopathy. After randomization, the authors divided the factors that impact patient satisfaction into three groups: (1) patient demographics, (2) aspects of the clinical encounter, including waiting time, time spent by the provider, and time since last visit, and (3) patient pain score. Of these factors, both time spent by the provider and pain score were found to have a statistically significant impact on patient satisfaction scores. This work is tremendously important. This is the first study that investigates Press Ganey survey in a spine surgery clinic. In fact, there are less than 200 publications in the literature that explore the results and implications of Press Ganey surveys in different medical specialties. The survey questions are

S. Ramhmdani and A. Bydon / The Spine Journal 16 (2016) 1290–1291

modified to fit clinical situations and reflect an appropriate clinical environment in accordance to each specialty (ie, emergency department vs. family clinic). Second, this topic is extremely important for patients, clinicians, and health-care organizations. Quality of care information of Medicarecertified hospitals is publicly reported and refreshed on a quarterly basis [6]. Patients may use this database as a factor when selecting clinicians, hospitals, and health-care plans. Physicians and hospitals might use this database as a tool to improve their understanding of patient satisfaction determinants. Third, the results of this study indicate that patient satisfaction rates stem from two types of variables: pain level (often non-modifiable) and time spent by the provider (modifiable). The impact of pain status on satisfaction scores and physician ratings is a global issue that has been repeatedly reported in similar articles in the literature, including orthopedic surgery and spine surgery [9,10]. Because pain is a subjective metric, a key point is to try to understand each patient’s interpretation of pain. Patients rate their quality of life based on their expectations, rather than their actual experiences [11]. Therefore, having a direct conversation with patients on what to anticipate from a recommended treatment could increase patient satisfaction scores. Statements such as “my proposed operation will not eliminate your pain but will rather help manage your pain” become ever more important. The strategy of “promising less and delivering more” becomes essential in softening patient expectations and improving their reported satisfaction. Equally important in shaping one’s satisfaction is the time spent with his or her provider. Several elements were thought to be related to an enhanced visit satisfaction, including starting the encounter with open-ended questions, empathizing with the patient’s concerns, and sitting during the encounter, rather than standing. Finally, the authors briefly summarized the pertaining literature, pointing out to other important findings that could affect patient satisfaction scores, including age, ethnicity, level of education, and high expectations. In conclusion, patient satisfaction with the level of health care provided is increasingly being used as a measure of quality. This study represents a timely starting point for other researchers in the field of spine surgery to thoroughly explore the factors that positively impact patients’ experiences. The authors ought to be commended for their work, which highlighted the importance of time spent by provider and pain level in shaping patients’ experiences. In light of the growing usage

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of patient satisfaction as a quality metric and determinant of reimbursement, we suspect that health-care providers will need to rethink the strategy of seeing as many patients as possible (and thus improve time spent with provider) and implement better screening tools so non-surgical pain patients are veered away from the surgeon’s office into the pain manager’s office (and thus improve pain level). What impact will increased “time spent with provider” have on hospital surgical volumes and budgets? Time will tell.

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