Modifiable and Nonmodifiable Factors Associated With Patient Satisfaction in Spine Surgery and Other Orthopaedic Subspecialties

A Retrospective Survey Analysis

Leah Steinmetz, BA; Dennis Vasquez-Montes, MS; Bradley C. Johnson, MD; Aaron J. Buckland, MBBS, FRACS; Jeffrey A. Goldstein, MD, FACS; John A. Bendo, MD; Thomas J. Errico, MD; Charla R. Fischer, MD


Curr Orthop Pract. 2019;30(6):555-560. 

In This Article


Patient satisfaction is a valuable metric for measuring the quality of care being delivered. As value-based care expands, satisfaction is being used more frequently to determine hospital reimbursement. Our study sought to understand how factors affect satisfaction in patients with spinal disorders compared to other orthopaedic patients, which may allow interventions that will increase patient satisfaction.

Because spine surgery has a high number of revision cases when compared to other subspecialties, patients are more likely to have greater interaction with the health care system compared to other orthopaedic subspecialties.[6–11] Additionally, spine surgery overwhelmingly has the lowest proportion of patients whose expectations are met after surgery as compared to hip and knee surgeries.[12] Thus, when it comes to procedural reimbursement within the VBP system, patient satisfaction scores have a higher potential to affect spine surgeons relative to other orthopaedic subspecialties. While there were no differences between patient satisfaction predictors in spine surgery and other orthopaedic subspecialties at the same institution in this study, there were both modifiable and nonmodifiable factors that were more predictive of satisfaction scores in both spine and nonspine orthopaedic subspecialties.

Nonmodifiable Factors

Nonmodifiable factors such as varying patient populations with regard to demographics, culture, and value systems can influence expectations from healthcare providers and perspectives on what constitutes satisfactory care.[13,14] Demographics such as age, gender, education, race, religion, location, and self-reported mental and physical health have proven to be significant indicators for patient satisfaction ratings.[14–19] In a study by LaVeist and Nuru-Jeter,[13] participants reported higher satisfaction with physicians from their own race. However, the study did not explore the effect of race concordance on quality of care, patient compliance, or utilization of medical services. The extent to which patient outcomes are affected by doctor-patient race or gender concordance is unclear. Saha et al.[20] demonstrated that African American, white, and Hispanic patients sought care from physicians of their own race because of personal preferences and language and not solely because of limited options. Additionally, they found that African-American patients who were treated by race-concordant physicians were more likely to rate their physician as excellent and to report receiving preventative care and needed medical care.[20] These data align with our finding that patients of the same race or ethnicity as their surgeon rated their physicians significantly higher and were more likely to recommend their physician. Our study shows that patients may be more satisfied when they align with the gender and ethnicity of the provider, indicating that factors outside the control of the provider can significantly influence patient satisfaction. This also challenges the validity of comparing patient satisfaction scores between populations that differ significantly with regard to one or more of these characteristics.

Additionally, we found that satisfaction scores were improved for elderly patients, which is consistent with other study analyses of overall satisfaction with medical care.[21,22] Conversely, younger, millennial-aged patients were more dissatisfied with care. This may be due to older patients being more likely to favorably rate their providers and tend to be more forgiving about increased wait times than their younger counterparts.[23]

Modifiable Factors

Other studies have established that physician communication behaviors such as lack of physician dominance, physician questions about psychosocial issues, information giving, positive affect and friendliness, discussing options, and encouraging patients to ask questions, are associated with patient satisfaction in the outpatient setting.[24–27] Our study confirms the importance of the patient-provider interaction by demonstrating that provider communication was the strongest predictor of LTR and PR for both the Division of Spine and the entire orthopaedic department. Our data also addresses other modifiable and nonmodifiable factors such as patient-staff interactions and patient-related demographic factors, which are poorly understood in the context of orthopaedic satisfaction ratings.

Patients rate their quality of life based on their expectations, rather than their actual experiences.[28] Mazur et al.[29] found that of patients who were referred to a spine surgeon for consultation, those who received recommendation for surgery had higher satisfaction scores than those who received a recommendation against surgery. They explained that because all of their patients were referred to a surgeon, the patients had expectations that they required surgery to receive definitive care and those who did not receive recommendations for surgery may not have had their expectations for definitive care achieved. Our findings are in agreement with the findings of Etier et al.,[5] who reported that a spine patient's perception of adequate time spent with the surgeon was the most significant factor affecting overall patient satisfaction.[5] This may explain why the correlation with LR and PR is stronger in the spine surgery setting than the nonspine orthopaedic subspecialties. Negarandeh et al.[30] noted that increased nursing interaction was found to have a positive effect on patient satisfaction. Similarly, we found a significant correlation with responsiveness of the hospital staff to LR.


We appreciate certain limitations to our study, including its retrospective nature. The number of responses for each subspecialty was not uniform since CG-CAHPS is dependent on patient participation and is limited by patient cooperation. The number of surveys returned for individual surgeons varied dramatically, leading to potential nonresponse bias. Thus, the power of comparative analysis was not evenly distributed. The anonymization of surveys also limited our ability to make direct comparisons between each patient's visit. A future prospective, multicenter study would decrease the biases seen in our analysis and increase the generalizability of results.