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

Disclosures

Spine. 2021;46(3):184-190.

Abstract and Introduction

Abstract

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

Introduction

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.

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Table 1. Patient Characteristics
	Nondepressed	Depressed	P
No. of patients	347	72
Age	67.74 ± 8.82	61.94 ± 13.21	<0.001*
Sex			0.072
Male	54.5%	42.4%
Female	45.5%	57.6%
BMI¹	30.15 ± 5.33	31.84 ± 8.39	0.108
White ethnicity	95.8%	97.2%	0.576
Tobacco smoker	45.2%	56.3%	0.088
Previous narcotic use	35.7%	43.1%	0.242
Charlson Comorbidity Index	3.08 ± 3.30	3.10 ± 3.66	0.975
Primary diagnosis			0.813
Spondylosis	11.3%	12.0%
Degenerative disc disease	5.7%	4.0%
Spinal stenosis	79.9%	84.0%
Disc displacement	3.1%	0.0%
Overall health			<0.001*
Excellent	4.7%	1.4%
Very good	35.8%	19.7%
Good	47.1%	40.8%
Fair	12.5%	32.4%
Poor	0%	5.6%
Education			0.203
8^th Grade	0.3%	1.4%
Some high school	1.5%	4.2%
High school	21.2%	23.9%
Some college	32.4%	36.6%
College+	44.7%	33.8%
Improvement in PROMIS-GPH^† Score	79.6%	71.8%	0.291
Length of stay^‡	3 (2–4)	3 (2–4)	0.950
Time between surgery and office visit When surveyed^‡	180 (52–356)	122 (49–301)	0.223
Survey response time^‡	6 (4–11)	5 (5–11)	0.307

BMI indcates body mass index.
^†PROMIS-GPH: Patient Reported Outcomes Measurement Information System Global Health Physical Health. Improvement defined as increase in score at 1-year postoperatively.
^‡Length of stay and survey response time reported in days as: median (IQR).
*All P values<0.05 were considered statistically significant.

Table 2. Percentages of Top-box CG-CAHPS Responses for Nondepressed Patients *Versus* Those With PHQ ≥10
	Nondepressed	Depressed^†	P
No. of patients	347	72
Access to Provider
Reported ''always'' able to get an appointment for when they wanted	64.3%	54.3%	0.257
Reported ''always'' waited 15 minutes or less before going to an examination room	24.4%	24.2%	0.972
Communication with Providers
Reported provider ''always'' showed respect for what they had to say	95.3%	85.5%	0.001*
Reported provider ''always'' listened carefully to them	88.8%	75%	0.002*
Reported provider ''always'' explained things in a way they could understand	89%	73.6%	0.001*
Reported that, during this visit, the provider spent enough time with them	86.5%	77.9%	0.072
Reported that, during this visit, the provider gave them easy to understand information about their health questions or concerns	91.8%	72.7%	<0.001*
Reported that, during this visit, the provider seemed to know the important information about their medical history	92.4%	82.6%	0.01*
Overall Provider Rating
Rated this provider as a 9 or 10 out of 10 overall	90%	3.9%	<0.001*
Reported that they would definitely recommend this provider to friends and family	94.7%	85.3%	0.005*

CG-CAHPS, Clinician and Group Consumer Assessment of Healthcare Providers and Systems; PHQ, Patient Health Questionnaire.
^†Patients with PHQ-9 score ≥10.
*All P values < 0.05 were considered statistically significant.

Table 3. Multivariable Logistic Regression Models Used to Determine the Association Between Preoperative Depression and Individual CG-CAHPS Survey Questions
Characteristic	Doctor Explain^†		Doctor Instructions^‡		Overall Provider Rating^§
Characteristic	Adjusted OR (95% CI)	P	Adjusted OR (95% CI)	P	Adjusted OR (95% CI)	P
Depression	0.32 (0.11–0.91)	0.032*	0.19 (0.06–0.63)	0.007*	0.19 (0.06–0.63)	0.007*
Age	1.19 (0.46–3.08)	0.714	0.73 (0.22–2.42)	0.605	0.93 (0.30–2.87)	0.902
Sex	1.85 (0.73–4.68)	0.196	2.82 (0.86–9.23)	0.086	1.61 (0.54–4.82)	0.392
Tobacco use	1.34 (0.53–3.38)	0.533	1.07 (0.35–3.29)	0.908	1.59 (0.53–4.71)	0.408
Overall health	1.11 (0.64–1.94)	0.708	1.41 (0.73–2.73)	0.314	1.12 (0.59–2.16)	0.723
PROMIS-GPH^\|\| Improvement	1.32 (0.48–3.65)	0.591	0.80 (0.22–2.93)	0.731	0.85 (0.24–2.99)	0.798

CI indicates confidence interval; CG-CAHPS, Clinician and Group Consumer Assessment of Healthcare Providers and Systems; OR, odds ratio.
*All P values < 0.05 were considered statistically significant.
^†Provider ''always'' explained things in a way you could understand.
^‡Provider ''always'' gave you easy to understand information about your health questions and concerns.
^§Rated this provider as a 9 or 10 out of 10 overall.
^||PROMIS-GPH: Patient Reported Outcomes Measurement Information System Global Health Physical Health. Improvement defined as increase in score at 1-year postoperatively.