Reserch Originl Investigtion Reltionship Between Hospitl Performnce on Ptient Stisfction Survey nd Surgicl Qulity Greg D. Scks, MD, MPH; Elise H. Lwson, MD, MSHS; Aron J. Dwes, MD; Mrci M. Russell, MD; Melind Mggrd-Gibbons, MD, MSHS; Dvid S. Zingmond, MD, PhD; Clifford Y. Ko, MD, MS, MSHS IMPORTANCE The Centers for Medicre nd Medicid Services include ptient experience s core component of its Vlue-Bsed Purchsing progrm, which ties finncil incentives to hospitl performnce on rnge of qulity mesures. However, it remins uncler whether ptient stisfction is n ccurte mrker of high-qulity surgicl cre. Invited Commentry pge 865 CME Quiz t jmnetworkcme.com OBJECTIVE To determine whether hospitl performnce on ptient stisfction survey is ssocited with objective mesures of surgicl qulity. DESIGN, SETTING, AND PARTICIPANTS Retrospective observtionl study of prticipting Americn College of Surgeons Ntionl Surgicl Qulity Improvement Project (ACS NSQIP) hospitls. We used dt from linked dtbse of Medicre inptient clims, ACS NSQIP, the Americn Hospitl Assocition nnul survey, nd Hospitl Compre from December 2, 2004, through December 31, 2008. A totl of 103 866 ptients older thn 65 yers undergoing inptient surgery were included. Hospitls were grouped by qurtile bsed on their performnce on the Hospitl Consumer Assessment of Helthcre Providers nd Systems survey. Controlling for preopertive risk fctors, we creted hierrchicl logistic regression models to predict the occurrence of dverse postopertive outcomes bsed on hospitl s ptient stisfction scores. MAIN OUTCOMES AND MEASURES Thirty-dy postopertive mortlity, mjor nd minor complictions, filure to rescue, nd hospitl redmission. RESULTS Of the 180 hospitls, the overll men ptient stisfction score ws 68.0% (first qurtile men, 58.7%; fourth qurtile men, 76.7%). Compred with ptients treted t hospitls in the lowest qurtile, those t the highest qurtile hd significntly lower risk-djusted odds of deth (odds rtio = 0.85; 95% CI, 0.73-0.99), filure to rescue (odds rtio = 0.82; 95% CI, 0.70-0.96), nd minor compliction (odds rtio = 0.87; 95% CI, 0.75-0.99). This trnslted to reltive risk reductions of 11.1% (P =.04), 12.6% (P =.02), nd 11.5% (P =.04), respectively. No significnt reltionship ws noted between ptient stisfction nd either mjor compliction or hospitl redmission. CONCLUSIONS AND RELEVANCE Using ntionl smple of hospitls, we demonstrted significnt ssocition between ptient stisfction scores nd severl objective mesures of surgicl qulity. Our findings suggest tht pyment policies tht incentivize better ptient experience do not require hospitls to scrifice performnce on other qulity mesures. JAMA Surg. 2015;150(9):858-864. doi:10.1001/jmsurg.2015.1108 Published online June 24, 2015. Author Affilitions: Deprtment of Surgery, Dvid Geffen School of Medicine, University of Cliforni, Los Angeles (Scks, Lwson, Dwes, Russell, Mggrd-Gibbons, Ko); VA Greter Los Angeles Helthcre System, Los Angeles, Cliforni (Scks, Lwson, Dwes, Russell, Mggrd-Gibbons, Ko); Deprtment of Medicine, Dvid Geffen School of Medicine, University of Cliforni, Los Angeles (Zingmond). Corresponding Author: Greg D. Scks, MD, MPH, Deprtment of Surgery, Dvid Geffen School of Medicine, University of Cliforni, Los Angeles, 10833 Le Conte Ave, 72-215 CHS, Los Angeles, CA 90095 (gscks@mednet.ucl.edu). 858 (Reprinted) jmsurgery.com
Ptient Stisfction nd Surgicl Qulity Originl Investigtion Reserch Mesures of ptient experience re now widely ccepted s core components of helth cre qulity. 1,2 Accordingly, the Centers for Medicre nd Medicid Services (CMS) now mesure nd publicly report ptient stisfction using the Hospitl Consumer Assessment of Helthcre Providers nd Systems (HCAHPS) survey. 3 New CMS pyment strtegies likewise im to encourge high-vlue cre by ttching percentge of hospitl reimbursement to performnce on vrious qulity mesures relting to clinicl processes of cre, certin risk-djusted outcomes, efficiency, nd ptient experience of cre. 4 In 2015, 30% of hospitl s weighted performnce score ws bsed on mesures of ptient experience, thereby creting strong incentive for hospitls to deliver cre tht is ptient centered. 5 However, severl studies tht hve explored the reltionship between ptient stisfction nd other, more objective mesures of qulity hve produced contrdictory findings. Some suggest tht ptient perception of helth cre qulity correltes positively with certin process 6,7 nd outcome 7-10 mesures, while others demonstrte either the lck of reltionship or n inverse reltionship. 11-13 One study even linked higher stisfction scores to higher mortlity rtes. 14 Within the field of surgery, results re eqully inconclusive. Recent studies hve shown no ssocition between ptient stisfction nd dherence to the Surgicl Cre Improvement Project process mesures 10,15 or the occurrence of postopertive complictions 10 nd mortlity. 16 In contrst, study using lrge smple of hospitls demonstrted tht higher ptient stisfction ws ssocited with lower postopertive mortlity, redmissions, nd length of sty. 17 However, tht study relied exclusively on dministrtive clims dt, which limits the bility to compre rtes of postopertive complictions. 18-20 The reltionship between hospitl performnce on ptient stisfction mesures nd objective mesures of surgicl qulity is of gret interest to policy mkers. A strong, positive correltion between the two would suggest tht mesuring both would be redundnt, dding little to wht is lredy known bout hospitl qulity. A negtive correltion, on the other hnd, would cution tht incentivizing one of these mesures could compromise efforts to improve the other. Finlly, the bsence of reltionship would suggest independent domins of qulity, ech wrrnting individul ttention. To exmine this reltionship, we used dt from ntionl smple of hospitls to determine whether there is n ssocition between objective mesures of surgicl qulity, s mesured by risk-djusted rtes of postopertive complictions, filure to rescue, redmissions, nd mortlity, nd ptient-centered cre, s mesured by hospitl performnce on the HCAHPS survey. Methods Dt Sources nd Study Smple We linked dt from 4 sources from December 2, 2004, through December 31, 2008: (1) Medicre inptient clims, (2) the Americn College of Surgeons Ntionl Surgicl Qulity Improvement Project (ACS NSQIP), (3) the Americn Hospitl Assocition nnul survey, nd (4) Hospitl Compre. These yers of dt were mde vilble by CMS s prt of collbortive reserch contrct. The dt merge between Medicre clims nd ACS NSQIP is described in detil elsewhere. 21 In brief, Medicre dt were obtined from the 100% Medicre Provider Anlysis nd Review file nd linked t the ptient level with ACS NSQIP dt using indirect ptient identifiers nd deterministic linkge lgorithm. The vlidity of the linkge procedure ws supported by the excellent greement on ptientlevel coding of mortlity (κ = 0.969). 21 The ACS NSQIP registry is n institution-bsed, multispecilty, clinicl registry for ptients undergoing surgery. Dt collected include preopertive risk fctors, type of opertion performed, nd detils on more thn dozen postopertive complictions, including mortlity. Ptient stisfction dt were obtined from the CMS Hospitl Compre website for 2008, the first yer these dt were publicly reported. 3 Using the linked dt sets, our study popultion included Medicre ptients older thn 65 yers who underwent n opertion t prticipting ACS NSQIP hospitl during the study period. Ptients were excluded if they underwent surgery t hospitls tht hd fewer thn 20 cses represented in our dt (86 ptients treted t 8 hospitls) or if ptient stisfction dt were unvilble (17 117 ptients treted t 29 hospitls). The study design nd procedures were pproved by the RAND Helth institutionl review bord. Becuse the study ws retrospective, informed consent ws not required. Vribles We nlyzed 5 seprte 30-dy outcomes t the ptient level: postopertive mortlity, ny mjor compliction, ny minor compliction, filure to rescue (deth fter ny compliction), nd redmission. Mjor complictions included ny of the following, s defined by ACS NSQIP: orgn-spce surgicl site infection, wound dehiscence, pneumoni, respirtory filure, pulmonry embolism, cute renl filure, stroke, com, myocrdil infrction, crdic rrest, bleeding requiring trnsfusion, sepsis or septic shock, nd return to the operting room. Minor complictions, lso in ccordnce with ACS NSQIP definitions, included superficil or deep-spce surgicl site infection, deep vein thrombosis, progressive renl filure, or urinry trct infection. Hospitl redmissions were nlyzed only for ptients who survived to dischrge. Our primry predictor of interest ws hospitl performnce on the HCAHPS survey, which is the primry component of the Ptient Experience of Cre domin in CMS s Vlue- Bsed Purchsing progrm. 3 The HCAHPS survey consists of 27 questions sked to recently dischrged ptients bout their hospitl sty nd encompsses vrious spects of the hospitl experience, such s physicin nd nurse communiction, responsiveness of stff, nd the clenliness nd quietness of the hospitl environment. Detils on the survey s psychometrics hve been published elsewhere. 22-24 Two questions pertining to the ptient s globl impression of cre received served s our primry mesure of ptient stisfction. We creted composite score for ptient stisfction by tking the verge of the responses to 2 questions: (1) the number of ptients reporting tht they would recommend the hospitl to jmsurgery.com (Reprinted) JAMA Surgery September 2015 Volume 150, Number 9 859
Reserch Originl Investigtion Ptient Stisfction nd Surgicl Qulity fmily or friends, nd (2) the number of ptients giving the hospitl globl rting of 9 or 10 out of 10. We chose these items for 2 resons. First, this is consistent with much of the previous literture. 6,10,17 Second, these mesure globl ssessment of ptient experience, one tht is less susceptible to bis from single negtive experience. Our preliminry nlyses demonstrted very strong correltion between responses to these 2 questions (Spermn ρ = 0.91). We then grouped hospitls into qurtiles bsed on their performnce on this composite score. To djust for ptient condition, we controlled for preopertive risk fctors s recorded by ACS NSQIP: ge, sex, dmission source (home, cute cre fcility, other), Americn Society of Anesthesiologists clss, functionl sttus (independent, prtilly dependent, fully dependent), wound clss (clen/ clen-contminted, contminted, dirty), emergency cse, nd number of comorbidities, including dibetes mellitus, dyspne (t rest or on exertion), ventiltor dependence, chronic obstructive pulmonry disese, myocrdil infrction within 6 months, congestive hert filure, hypertension requiring mediction, renl filure, presence of scites, disseminted cncer, recent chemotherpy or rdition tretment, weight loss, steroid use, bleeding disorder, or preopertive sepsis. We controlled for procedure type by clculting liner risk probbilities for 23 Current Procedurl Terminology buckets grouped by orgn system; we clculted seprte liner risks for ech outcome modeled in ccordnce with ACS NSQIP methods. 25 We lso controlled for hospitl chrcteristics, s defined by the Americn Hospitl Assocition nnul survey, including hospitl ownership (public, for profit, nonprofit), hospitl size (>400 beds [lrge]; 100-400 beds [medium]; <100 beds [smll]), teching hospitl sttus, nd hospitl census region (Midwest, Northest, South, nd West). Sttisticl Anlysis Dt preprtion nd nlyses were performed using SAS version 9.3 (SAS Institute, Inc) nd Stt version 13.1 (SttCorp LP) sttisticl softwre. We compred ptient nd hospitl chrcteristics cross ptient stisfction qurtiles using χ 2 tests for ctegoricl vribles nd Wilcoxon tests for continuous vribles. P <.05 ws considered sttisticlly significnt. We modeled the reltionship between ech mesure of hospitl qulity nd ptient stisfction qurtiles using hierrchicl logistic regression. Ech model controlled for ptient risk fctors nd procedure type s well s hospitl structurl chrcteristics. Mrginl effects of ptient stisfction qurtiles were lso estimted. Results Our study smple consisted of 103 866 ptients treted t 180 unique hospitls. Tble 1 summrizes the overll study popultion divided by hospitl qurtile of ptient stisfction scores. The men ge ws 75.5 yers, nd the mjority were femle (51.5%). Most ptients were functionlly independent (92.8%) nd dmitted from home (92.7%). In generl, ptient chrcteristics differed significntly cross ptient stisfction qurtiles. For exmple, there were significnt differences cross qurtiles in the number of ptients who smoked or hd dibetes, chronic obstructive pulmonry disese, congestive hert filure, hypertension, scites, nd preopertive sepsis. In most cses, the prevlence of ech comorbidity ws highest mong ptients treted t hospitls in the lowest stisfction qurtile. Overll ptient stisfction scores rnged from 44.8% to 82.8% (men [SD], 68.0% [7.2%]). The men overll ptient stisfction score ws 58.7% for the first qurtile, 66.2% for the second qurtile, 70.8% for the third qurtile, nd 76.7% for the fourth qurtile (Tble 2). Of the 180 hospitls in our dt, most were nonprofit (82.8%), lrge (57.8%), nd teching hospitls (52.2%). Hospitls were most commonly locted in the Midwest (36.7%) followed by the Northest (23.9%). We found no significnt ssocition between ptient stisfction qurtile nd hospitl size or census region. We did, however, note significnt differences with regrd to teching hospitl sttus nd hospitl ownership (P =.01 nd.03, respectively). The lowest ptient stisfction qurtile hd more nonteching hospitls thn teching hospitls (65.2% vs 34.8%, respectively), while the highest qurtile more commonly hd teching hospitls thn nonteching hospitls (61.4% vs 38.6%, respectively). Hospitls in the highest stisfction qurtile were most frequently nonprofit (93.2%). In multivrite regression, we found tht ptient stisfction qurtile ws significntly ssocited with 30-dy mortlity nd filure to rescue (Tble 3). In comprison with ptients treted t the lowest qurtile, those t the highest qurtile hd 15% lower odds of deth within 30 dys (odds rtio [OR] 0.85; 95% CI, 0.73-0.99) nd 18% lower odds of filure to rescue (OR = 0.82; 95% CI, 0.70-0.96). Ptients treted t the highest stisfction qurtile hospitls lso experienced 13% lower odds of minor compliction (OR = 0.87; 95% CI, 0.75-0.99). Mjor complictions did not rech sttisticl significnce. We found nonliner reltionship between ptient stisfction nd hospitl redmission. Ptients treted t hospitls in the second qurtile hd significntly lower odds of redmission (OR = 0.90; 95% CI, 0.82-0.98), while those treted t hospitls in the third or highest qurtile did not hve significntly higher odds of redmission. The Figure displys the risk-djusted rte of ech outcome cross ptient stisfction qurtiles. Compred with ptients treted in hospitls with the lowest stisfction scores, those treted t hospitls with the highest stisfction scores hd 0.6% lower rte of 30-dy mortlity (reltive risk reduction = 11.1%; P =.04),2.2%lowerrteoffiluretorescue(reltive risk reduction = 12.6%; P =.02), 1.0% lower rte of mjor compliction (P =.11), nd 1.2% lower rte of minor compliction (reltive risk reduction = 11.5%; P =.04). Ptients in the third qurtile of ptient stisfction hd the lowest risk-djusted rtes of both mortlity nd filure to rescue, lthough these rtes were not sttisticlly significntly different from those in the highest qurtile (P =.18 for mortlity nd P =.12 for filure to rescue). For redmission, ptients in the second qurtile hd the lowest risk-djusted 30-dy redmission rte (11.0% vs 12.0% for the lowest qurtile; P =.02), while ptients treted t hospitls in the highest qurtile hd the highest rte (12.4%; P =.45 for comprison with the lowest qurtile). 860 JAMA Surgery September 2015 Volume 150, Number 9 (Reprinted) jmsurgery.com
Ptient Stisfction nd Surgicl Qulity Originl Investigtion Reserch Tble 1. Chrcteristics of 103866 Ptients by Hospitl Performnce in Ptient Stisfction Ptient Stisfction Score Qurtile Chrcteristic Overll First Second Third Fourth P Vlue Age, men, y 75.5 75.6 75.6 75.4 75.3 <.001 Femle, % 51.5 53.6 52.1 50.9 50.6 <.001 Admitted from home, % 92.7 92.3 92.9 92.7 92.7.25 ASA clss, medin 2.9 3.0 3.0 2.9 2.9 <.001 Independent functionl sttus, % 92.8 82.9 82.0 85.4 87.1 <.001 Wound clss, medin 1.2 1.3 1.3 1.2 1.2 <.001 Comorbidities, % Smoker 14.4 16.6 14.4 13.9 13.6 <.001 Dibetes mellitus 22.0 23.0 22.5 21.8 21.2 <.001 Dyspne t rest or with exertion 19.1 18.0 19.3 20.2 18.5 <.001 Ventiltor dependent 1.8 2.1 1.9 1.7 1.7.01 COPD 11.2 13.0 11.3 11.3 10.2 <.001 Recent myocrdil infrction 1.8 1.6 1.6 2.0 1.7.01 Congestive hert filure 2.6 3.1 2.7 2.8 2.2 <.001 Hypertension requiring mediction 74.3 75.8 75.0 74.9 72.6 <.001 Renl filure 1.1 1.2 1.0 1.2 0.9 <.001 Ascites 2.0 2.6 2.1 1.8 2.0 <.001 Disseminted cncer 3.6 3.4 2.9 3.7 4.0 <.001 Current chemotherpy 1.4 1.5 1.2 1.4 1.5.02 Current rdiotherpy 1.2 1.1 1.0 1.2 1.5 <.001 >10% Weight loss in lst 6 mo 4.4 4.6 4.1 4.4 4.6.02 Current steroid use 4.4 3.9 4.0 4.9 4.5 <.001 Bleeding disorder 12.5 13.1 13.4 11.0 12.8 <.001 Preopertive sepsis 11.7 14.1 13.3 11.2 9.8 <.001 Emergency cse, % 15.5 18.3 15.7 15.6 13.8 <.001 Abbrevitions: ASA, Americn Society of Anesthesiologists; COPD, chronic obstructive pulmonry disese. Ptient chrcteristics were obtined from the Americn College of Surgeons Ntionl Surgicl Qulity Improvement Project registry; ptient stisfction scores were clculted from the Hospitl Consumer Assessment of Helthcre Providers nd Systems survey bsed on the verge percentge of respondents who sid they would recommend the hospitl to fmily nd friends nd who rted the hospitl s either 9 or 10 of 10; nd ptient stisfction qurtiles were clculted t the hospitl level. Discussion The extent to which mesures of ptient experience correlte with more objective mrkers of helth cre qulity remins uncler. Using ntionl smple of ptients, we found significnt ssocitions between both ptient nd hospitl chrcteristics nd hospitl-level mesures of ptient stisfction. After controlling for these differences, ptients treted t hospitls with higher ptient stisfction scores experienced lower rtes of 30- dy mortlity, filure to rescue, nd minor complictions. However, we were unble to demonstrte significnt differences in mjor complictions or hospitl redmissions. The reltionship between ptient stisfction nd hospitl qulity hs long been controversil. More thn 30 yers go, Donbedin rgued, to the extent tht client stisfction is judgment on the qulity of cre, it is not prt of the definition of qulity. 26 Over the yers, this skepticism regrding the vlidity of ptient stisfction s qulity metric hs been supported by severl studies, 11,12,16,27,28 including one notble study by Fenton et l 14 tht found high stisfction scores were ssocited with higher rtes of mortlity. Within surgery, 2 recent rticles lso suggested the bsence of ny reltionship between ptient stisfction nd surgicl qulity 15,16 ; however, both were limited by smll smple of hospitls nd studied limited number of surgicl outcomes. Combined, these studies hve led some to question whether ptient stisfction should be used s mrker of hospitl qulity. 15 In contrst, our study dds to growing body of literture suggesting tht providing high-qulity ptient experience need not preclude the delivery of high-qulity cre. 6,9,29,30 One recent study used Medicre dt to demonstrte tht high ptient stisfction scores were ssocited with higher complince on the Surgicl Cre Improvement Project mesures, fewer redmissions, decresed length of sty, nd lower mortlity following surgery. 17 Another study, using dministrtive dt from the University HelthSystem Consortium, found no reltionship between ptient stisfction scores nd complince with process mesures, ptient sfety indictors, nd length of sty but did find n ssocition between high stisfction scores nd lower risk-djusted mortlity. 10 Our study is the first, to our knowledge, to use high-qulity clinicl dt from ntionl smple, llowing for robust risk djustment nd mesurement of importnt clinicl outcomes tht re not me- jmsurgery.com (Reprinted) JAMA Surgery September 2015 Volume 150, Number 9 861
Reserch Originl Investigtion Ptient Stisfction nd Surgicl Qulity Tble 2. Chrcteristics of 180 Hospitls nd Undjusted Outcome Mesures by Performnce in Ptient Stisfction Column % Ptient Stisfction Score Qurtile Chrcteristic Overll First Second Third Fourth P Vlue Stisfction score, men, % 68.0 58.7 66.2 70.8 76.7 <.001 Ownership Nonprofit 82.8 76.1 75.0 87.0 93.2 Government 11.7 15.2 11.4 13.0 6.8.03 For profit 5.6 8.7 13.6 0.0 0.0 Hospitl size Lrge 57.8 54.4 65.9 52.2 59.1 Smll or medium 42.2 45.7 34.1 47.8 40.9.57 Teching hospitl Yes 52.2 34.8 65.9 47.8 61.4 No 47.8 65.2 34.1 52.2 38.6.01 Region Midwest 36.7 43.5 31.8 37.0 34.1 Northest 23.9 19.6 27.3 26.1 22.7 South 18.3 6.5 27.3 17.4 22.7.30 West 21.1 30.4 13.6 19.6 20.5 Hospitl chrcteristics were determined from the Americn Hospitl Assocition nnul survey; ptient stisfction scores were clculted from the Hospitl Consumer Assessment of Helthcre Providers nd Systems survey bsed on the verge percentge of respondents who sid they would recommend the hospitl to fmily nd friends nd who rted the hospitl s either 9 or 10 of 10; nd ptient stisfction qurtiles were clculted t the hospitl level. Tble 3. Multivrite Anlysis of Hospitl Ptient Stisfction Scores nd Ptient Outcomes Ptient Stisfction Score Qurtile Odds Rtio (95% CI) Deth Filure to Rescue Mjor Compliction Minor Compliction Redmission First 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] Second 0.87 (0.75-1.01) 0.78 (0.66-0.91) b 0.95 (0.86-1.05) 0.97 (0.84-1.11) 0.90 (0.82-0.98) Third 0.78 (0.67-0.90) b 0.73 (0.62-0.85) b 0.95 (0.86-1.05) 0.96 (0.84-1.09) 0.98 (0.90-1.07) Fourth 0.85 (0.73-0.99) b 0.82 (0.70-0.96) b 0.92 (0.83-1.02) 0.87 (0.75-0.99) b 1.04 (0.95-1.13) Ptient stisfction scores were clculted from the Hospitl Consumer Assessment of Helthcre Providers nd Systems survey bsed on the verge percentge of respondents who sid they would recommend the hospitl to fmily nd friends nd who rted the hospitl s either 9 or 10 of 10; ptient stisfction qurtiles were clculted t the hospitl level. b Sttisticlly significnt t P <.05. sured relibly with dministrtive dt, such s postopertive complictions nd filure to rescue. Considered together, these studies provide importnt evidence in support of CMS s inclusion of ptient experience s core component of its Vlue- Bsed Purchsing progrm. 31 However, in line with the conflicting results of previous literture, our findings drw ttention to the complex reltionship between ptient stisfction nd certin mesurements of surgicl qulity. While we demonstrted significnt reductions in severl postopertive dverse events in hospitls with high ptient stisfction scores, the reltionships were not lwys liner. For exmple, for both mortlity nd filure to rescue, the lowest risk-djusted rtes were noted in the second highest qurtile, with slightly higher rtes (lthough not sttisticlly significntly higher) in the highest qurtile. Similrly, riskdjusted redmissions were lowest in the second qurtile nd highest in the highest ptient stisfction qurtile. The nonliner reltionship between ptient stisfction nd surgicl qulity hs severl possible explntions nd implictions. First, insted of reflecting ptient s helth cre experience, ptient stisfction my ctully be more closely relted to ptient-specific fctors, such s expecttions of cre 32 or their current stte of helth. 9 Furthermore, in recollecting their experiences, ptients tend to focus disproportiontely on only few key moments of their encounter, which my not be representtive of their entire helth cre experience. 33,34 Without perfect mesurement of ptient experience, its reltionship with other mesures of qulity my be tenuous. Second, ptient stisfction my fll into different domin of helth cre qulity from other surgicl qulity metrics, which my prtilly explin the conflicting findings in the ptient stisfction literture s well s the inconsistent findings in our study. 1,35 Yet, the bsence of reltionship nd the occsionl nonliner reltionship between these qulity domins 862 JAMA Surgery September 2015 Volume 150, Number 9 (Reprinted) jmsurgery.com
Ptient Stisfction nd Surgicl Qulity Originl Investigtion Reserch Figure. Risk-Adjusted Rtes of 30-Dy Surgicl Outcomes by Ptient Stisfction Qurtile Lowest qurtile Second qurtile Third qurtile Highest qurtile Risk-Adjusted Rte, % 20 18 16 14 12 10 8 6 4 2 0 Mortlity Filure to Rescue Minor Compliction Surgicl Outcome Mjor Compliction Redmission Minor complictions include superficil or deep-spce surgicl site infection, deep vein thrombosis, progressive renl filure, or urinry trct infection. Mjor complictions include orgn-spce surgicl site infection, wound dehiscence, pneumoni, respirtory filure, pulmonry embolism, cute renl filure, stroke, com, myocrdil infrction, crdic rrest, bleeding requiring trnsfusion, sepsis or septic shock, nd return to the operting room. Sttisticlly significnt difference in comprison with the first qurtile (P <.05). re not necessrily critique of either s vlue s qulity metric; ech is simply mesuring n independent component of lrger definition of qulity. Third, ptient stisfction itself is composed of multiple domins nd therefore vries depending on the mesurement tool. 9 The HCAHPS survey, which is completed by ptients within 42 dys of dischrge, is the most widely used instrument but my not ppropritely cpture the domins of ptient stisfction most relevnt to surgicl ptients. 36 A surgery-specific version of HCAHPS, the Consumer Assessment of Helthcre Providers nd Systems Surgicl Cre Survey, ws recently endorsed by the Ntionl Qulity Forum nd will likely provide more ccurte ssessment of ptient stisfction mong surgery ptients. 37 There re limittions to our study. First, severl yers hve pssed since this unique dt set ws creted s prt of contrct with CMS, during which time temporl trends my hve led to improvements in both ptient stisfction scores nd surgicl outcomes. Nevertheless, while the vlues of these 2 mesures my hve chnged, there is no reson to suspect tht the reltionship between them would differ in more recent smple. Furthermore, such n nlysis would not be possible with more recent ACS NSQIP dt owing to the lck of hospitl identifiers in public use files. Our dt re therefore uniquely ble to test the reltionship between ptient stisfction nd surgicl outcomes. Second, becuse prticiption in ACS NSQIP is voluntry, our dt represent convenience smple of hospitls nd our results my not be generlizble to other hospitls in the United Sttes. Third, becuse we found older, sicker ptients being treted t hospitls with low stisfction scores (lthough mny of these differences my not be cliniclly significnt), it is possible tht our risk-djustment strtegy ws indequte to fully control for these differences. Nonetheless, we used high-qulity clinicl dt from ACS NSQIP, which represents the most dvnced risk-djustment technique vilble. Fourth, HCAHPS dt were collected from smple of ll dischrged ptients, not just those undergoing surgery. While no ptient-level dt re currently vilble to determine whether individul ptient stisfction is ssocited with the qulity of cre received, there is evidence to suggest tht hospitls tht perform well on 1 qulity mesure tend to do just s well on other mesures. 38,39 Finlly, our dt set consists only of Medicre ptients, which my limit the generlizbility of our findings to nonelderly ptients. As Medicre ptients undergo lrge proportion of surgicl procedures, hve higher rtes of morbidity nd mortlity, nd represent the precise trget popultion for the CMS Vlue-Bsed Purchsing progrm, we believe our results cn help inform future policy decisions. Conclusions Using ntionl smple of ptients undergoing surgery, we demonstrted significnt ssocition between hospitl performnce on ptient stisfction survey nd objective mesures of surgicl qulity. Ptients treted t hospitls with the highest stisfction scores experienced lower rtes of postopertive mortlity, filure to rescue, nd minor complictions. Our findings suggest tht pyment policies tht incentivize better ptient experience do not require hospitls to scrifice performnce on other qulity mesures. ARTICLE INFORMATION Accepted for Publiction: Mrch 16, 2015. Published Online: June 24, 2015. doi:10.1001/jmsurg.2015.1108. Author Contributions: Dr Scks hd full ccess to ll of the dt in the study nd tkes responsibility for the integrity of the dt nd the ccurcy of the dt nlysis. Study concept nd design: Scks, Lwson, Dwes, Zingmond, Ko. Acquisition, nlysis, or interprettion of dt: Scks, Lwson, Dwes, Russell, Mggrd-Gibbons, Zingmond. Drfting of the mnuscript: Scks. Criticl revision of the mnuscript for importnt intellectul content: All uthors. Sttisticl nlysis: Scks, Lwson, Dwes, Russell, Zingmond, Ko. Administrtive, technicl, or mteril support: Dwes. Study supervision: Russell, Mggrd-Gibbons, Zingmond, Ko. Conflict of Interest Disclosures: None reported. Funding/Support: Drs Scks nd Dwes were supported by the Robert Wood Johnson Foundtion Clinicl Scholrs Progrm t the University of Cliforni, Los Angeles. jmsurgery.com (Reprinted) JAMA Surgery September 2015 Volume 150, Number 9 863
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JAMA Intern Med. 2013;173(14):1351-1357. 864 JAMA Surgery September 2015 Volume 150, Number 9 (Reprinted) jmsurgery.com