The Impact of Preoperative Depression on Patient Satisfaction With Spine Surgeons in the Outpatient Setting

Hammad A. Khan, BS; Nicholas M. Rabah, BS; Robert D. Winkelman, MD, MS; Jay M. Levin, MD, MBA; Thomas E. Mroz, MD; Michael P. Steinmetz, MD


Spine. 2021;46(3):184-190. 

In This Article

Abstract and Introduction


Study Design: Retrospective review.

Objective: The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery.

Summary of Background Data: The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear.

Methods: Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined.

Results: Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06–0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11–0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06–0.63, P = 0.007).

Conclusion: Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.

Level of Evidence: 3


Patient experience metrics have become increasingly important as healthcare reimbursements have shifted toward incentivizing value-based care.[1–4] In the outpatient setting, the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey asks patients to evaluate their experiences during clinic visits.[5] While not currently mandated by the Centers for Medicare and Medicaid Services (CMS), many health systems use CG-CAHPS ratings for physician incentive programs,[6] quality improvement initiatives,[7] and comparative physician performance information that can be made publicly available and utilized by prospective patients when selecting physicians. It is therefore of interest to understand modifiable and nonmodifiable factors that may influence patient satisfaction scores.

In the lumbar spine surgery population, preoperative depression has been shown to predict poor patient-reported outcomes,[8–12] lower satisfaction with outcomes,[12,13] and lower satisfaction with the inpatient hospital experience.[14] These studies not only suggest that preoperative depression should be included in case-mix adjustments made by CMS to hospital performance metrics that determine reimbursement, but also highlight the potential utility of screening, counseling, and treating preoperative depression in improving patient outcomes and satisfaction after lumbar spine surgery. It remains unclear, however, whether preoperative depression has an impact on CG-CAHPS patient satisfaction ratings in the outpatient spine clinic. As such, the present study aimed to evaluate the association of preoperative depression and CG-CAHPS scores at outpatient spine clinic visits following lumbar surgery.