Patient-Related Factors Predict Satisfaction With Spine Surgery

Commentary by Richard L. Skolasky, Jr., ScD

older couple, woman and manPatient satisfaction with elective spine surgery for degenerative diseases is influenced by whether they achieve clinically significant improvement in pain and disability at 1-year postsurgery, are Medicaid recipients or are uninsured, and have worse pain and disability at baseline, according to a study published in the August issue of Neurosurgery.

“Satisfaction metrics are emerging as the center of the pay-per performance model for spine care,” said senior author Clinton J. Devin, MD, Associate Professor of Neurological Surgery and of Orthopaedic Surgery and Rehabilitation at Vanderbilt University Medical Center in Nashville, TN. “Patient satisfaction is defined as ‘the degree to which a patient feels they have received high-quality health care,’ and can be affected by numerous factors related to the provider, the payer, and the patient,” Dr. Devin said.1-7 Thus, Dr. Devin said it is essential for practitioners to identify factors that may affect patient satisfaction in order to appropriately set expectations and stratify patients.

To evaluate whether preoperative factors or patient-reported outcomes could predict dissatisfaction following spine surgery, the authors examined data from a prospective longitudinal registry of patients (n=1,645) undergoing elective surgery for degenerative lumbar and cervical disease over a 2-year period from November 2010 to July 2013.

At baseline and 1-year postsurgery, the patients were asked to complete the Oswestry Disability Index (ODI)/Neck Disability Index (NDI), and numeric rating scale for back/neck and leg/arm pain. The North American Spine Society Satisfaction Questionnaire was used to assess patient satisfaction with surgery at 1-year followup.

Factors Affecting Patient Satisfaction
Overall, 1,362 patients (83%) were satisfied with surgery outcome at 1 year. After controlling for a range of patient-specific variables, the following factors were independent predictors of patient dissatisfaction:

  • inability to achieve minimal clinically important difference for ODI/NDI (P<0.001; odds ratio [OR]=4.215)
  • back/neck pain (P<0.001; OR=3.1)
  • leg/arm pain (P<0.001; OR=2.6)
  • Medicaid/uninsured payer status (P=0.04; OR=1.39)
  • higher baseline ODI/NDI (P=0.002; OR=1.11) and back/neck pain scores (P=0.002; OR=1.03)

Individualized Preoperative Counseling May Improve Satisfaction With Spine Surgery
“This study provides patients, physicians and the payers with tools to identify the individuals at risk of dissatisfaction in order to have realistic discussions about expectation,” Dr. Devin said. “Spine care providers should consider that patients who fail to achieve clinically significant difference in pain and disability at 1-year after surgery, those with Medicaid or uninsured payer status, and those presenting with worse pain and disability at baseline were less likely to be satisfied with the outcomes after elective surgery for degenerative spine diseases. Individualizing the patient preoperative counseling based on these patient-specific factors can improve the patient satisfaction with outcomes,” Dr. Devin said.

“Patient satisfaction is a complex outcome metric,” Dr. Devin said. “North American Spine Society satisfaction metric captures the satisfaction with surgery. Grade I or highest satisfaction grade is defined as ‘surgery met my expectations;’ which in itself reflects that satisfaction is highly dependent on patient expectations. In addition to defining the predictors of satisfaction, as described in this study, it is vital to understand patient expectations from surgery. This can be achieved if the patient and surgeon are provided with factual probabilities of achieving better or worse outcomes,” Dr. Devin said.

“We are in the process of developing such predictive model based calculators with Dr. McGirt and Dr. Asher as part of N2QOD that can be used during the preoperative discussion with patients regarding their individual outcomes,” Dr. Devin added. “This will help the providers and patients to set realistic expectations and achieve higher satisfaction. Nonetheless, this concept is still in the infancy phase and will require a strategically planned approach to test the feasibility of using this tool in clinical practice,” Dr. Devin said.


Richard L. Skolasky, Jr., ScD
Associate Professor, Orthopaedic Surgery and Physical Medicine & Rehabilitation
Director, Spine Outcomes Research Center
Johns Hopkins University
Baltimore, MD

It was with great anticipation that I read Dr. Chotai, et al’s paper on the association of patient-specific factors with dissatisfaction after elective surgery for degenerative spine disease. As a health services researcher interested in variability of patient-reported outcomes following surgery, I am keenly aware of the role that patient-specific factors play.

From the manuscript, the association between dissatisfaction with surgery and failure to reach a minimum clinically important difference in pain/disability supports what we have observed in our patient populations.1 With these symptoms being of great importance to patients, patients’ resolution drives how effective they rate their treatment.

As the U.S. healthcare system moves toward a system that rewards high quality care, the role of patient satisfaction will become more important as a proxy for quality. Because the authors focused their outcome measure solely on satisfaction with outcome at 1 year after surgery, ​​confounders were minimized. Oftentimes, satisfaction measures are reported that take into account satisfaction with such non-clinical factors as appointment process or facility characteristics. These are important factors, however, they do not represent the quality of the medical care provided. The authors are framing future research into this field to improve our understanding.

The authors’ finding that patients with Medicaid/uninsured or with more severe pain/disability at baseline were associated with dissatisfaction may have unintended consequences. These patients are in need of adequate spine care. Future study should examine modifiable patient factors that are associated with satisfaction in order to provide targets for intervention in order to maximize patient outcomes following surgery. This is something that we and other researchers are currently pursuing, as we strive to understand how to reduce variability in outcomes following spine surgery.

1. Skolasky RL, Albert TJ, Vaccaro AR, Riley LH 3rd. Spine J. 2009;9(3):232-239.

Updated on: 08/18/16
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