Depression is a well-known risk factor for less improvement on patient-reported outcomes (PROs) following cervical and lumbar surgery. Given that depressed patients tend to respond less favorably to health-related questionnaires, it seems likely that they may report less satisfaction with their physicians and hospital. The most commonly used patient satisfaction survey is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is administered by the Center for Medicare and Medicaid Services (CMS) and is used to adjust hospital reimbursement. Many health systems also use the data to evaluate physicians and adjust compensation. Now that HCAHPS data can affect reimbursement, it is important for physicians and hospitals to better understand factors that affect patient responses to these surveys. In order to evaluate the effect of pre-operative depression on HCAHPS scores following cervical spine surgery, Jay Levin and colleagues from the Cleveland Clinic evaluated 145 cervical spine surgery patients from 2013-2015 who had responded to the HCAHPS survey and also had baseline PROs (i.e. PHQ-9, EQ-5D, neck pain VAS). Forty-one patients were classified as having at least moderate depression (PHQ-9 score over 9), and the depressed patients were about 6 years younger and had worse baseline EQ-5D and neck pain VAS scores. There was a trend towards a higher proportion of female patients in the depressed group (59% in depressed group vs. 41% non-depressed, p = 0.06). In univariate analysis, they found that depressed patients were significantly less likely to report that their doctors always treated them with courtesy and respect (88% depressed vs. 97% non-depressed, p = 0.03) and less likely to report that doctors always listened carefully to them (78% depressed vs. 91% non-depressed, p = 0.03). There was also a trend towards depressed patients being less likely to rate the hospital as a 9 or 10 overall (68% vs. 81%, p = 0.1). Multivariate analysis controlling for demographic characteristics and baseline PROs demonstrated that depression was an independent predictor of reporting that their doctor did not always treat them with courtesy and respect (OR = 0.14, p = 0.04).
This paper has done a nice job demonstrating that depressed patients are less likely to be satisfied with their doctor's communication style following cervical spine surgery. This result comes as no surprise given the strong negative association between depression and PROs. I would have expected an even more pronounced effect on HCAHPS scores. There were many trends towards less satisfaction with nurses and hospitals that did not reach significance, and this likely reflects that the study was underpowered for these analyses. Only a minority of patients receive and then return the HCAHPS survey, so the authors only had 145 patients in their study, of whom 41 were depressed. This limits the power of all the analyses, especially the multivariate analysis. This paper begs the question of how HCAHPS data should be used, and also how hospitals and providers might be incentivized to game the system. While CMS can control for macro level data (i.e. proportion of patients on Medicaid, socioeconomic data, etc.), they do not collect meaningful data on the individual patient level (i.e. depression, educational attainment, work status, etc.). Controlling for the macro level data in large populations may be reasonable for hospital level results, however, this is probably not sufficient at the individual provider level. If these data are used for reimbursement and compensation, hospital systems and physicians may be incentivized to care for patients without risk factors for dissatisfaction. This could create even greater barriers to healthcare access for our most vulnerable patients, who tend to have medical and psychosocial comorbidities associated with worse outcomes and lower satisfaction. Healthcare administrators should be very cautious about how they use patient satisfaction data in determining reimbursement and compensation.
Please read Mr. Levin's article on this topic in the January 1 issue. Does this change your view of how patient satisfaction data like HCAHPS should be used? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor