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

Materials and Methods

Study Design and Data Acquisition

We conducted a retrospective review of patients who underwent lumbar spine surgery at an academic tertiary referral center and completed a CG-CAHPS survey at a postoperative office visit with their spine surgeon within 1 year of surgery between 2009 and 2017. This study was reviewed and approved by the institutional review board at the Cleveland Clinic Foundation. Patients who had completed CG-CAHPS surveys were identified through query of our institution's Patient Experience database using International Classification of Diseases, Ninth Revision (ICD-9) codes for lumbar spondylosis, lumbar degenerative disc disease, lumbar spinal stenosis, and lumbar disc displacement. Of these patients, those who underwent lumbar spine surgery were identified using Common Procedure Terminology (CPT) codes. All patients above age 18 years who received lumbar spine surgery and completed a CG-CAHPS survey at outpatient postoperative follow-up were included in this study.

The electronic medical record was retrospectively reviewed to collect preoperative patient characteristics such as age, sex, body mass index, ethnicity, tobacco use, previous narcotic use, Charlson Comorbidity Index, and education. A database of prospectively collected patient-reported health outcomes data was queried to obtain PRO metrics, including the pre- and 1-year postoperative Patient-Reported Outcomes Measurement Information System Global Health Physical Health (PROMIS-GPH) subscore and preoperative Personal Health Questionnaire 9 (PHQ-9). Postoperative self-reported overall health status was obtained from the CG-CAHPS survey completed during outpatient follow-up. The PROMIS-GPH instrument represents an overall evaluation of one's physical health using four items that measure overall physical health, physical functioning, pain, and fatigue.[15] The PROMIS-GPH utilizes item response theory to generate scores that are scaled to a US population mean of 50 with standard deviation of 10,[16] and its utility as a measure of physical health has been validated in patients with chronic low back pain.[17] The PHQ-9 is a validated screening tool for major depression[18–20] that adapts nine Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) criteria for major depressive disorder. Each of the nine questions is scored from 0 ("not at all") to 3 ("nearly every day") to generate a total score ranging from 0 to 27. Based on their PHQ-9 score, patients are classified as having mild (0–4), moderate (5–9), moderately severe (10–14), or severe (14–29) depression.[21] At our institution, the electronic health record notifies providers when patients screen positive for major depression on the PHQ-9. This allows providers to counsel patients, note whether the patient is under appropriate care, or place referrals for further depression workup as needed. In the present study, patients with preoperative PHQ-9 scores of ≥10 (moderate-to-severe depression) were included in the depressed cohort, as this cutoff has been shown to confer maximal sensitivity and specificity for major depressive disorder.[22,23]

Outcome Variables

The primary outcome measures of interest were 10 patient experience measures across three domains on the CG-CAHPS survey: Access to Provider, Communication with Providers, and Overall Provider Rating (OPR). Items analyzed within the "Access to Provider" domain were: Patient got appointment for care as soon as needed; and Patient saw provider within 15 minutes of appointment time. Items analyzed within the "Communication with Providers" domain were: Provider showed respect for what patients had to say; Provider listened carefully to patient; Provider explained things in a way that was easy to understand; Provider spent enough time with patient; Provider gave easy to understand information about health questions or concerns; and Provider knew important information about patient's medical history. Items analyzed within the "OPR" domain were: Overall rating of provider; and Patient would recommend this provider to friends and family. Patients were classified as "satisfied" for a given item on the survey if they provided a "top-box" survey response, or the single most positive response to the particular survey item. However, for the overall rating of a provider item, a score of either 9 or 10 out of 10 is considered a top-box response. In contrast, if a non-top box response was reported, patients were classified as "unsatisfied" for the given survey item.

Statistical Analysis

Patient characteristics between the depressed and non-depressed cohorts were compared using Pearson χ 2 test for categorical variables and Student t test for continuous variables. Survey response time was compared between cohorts using the Mann-Whitney U test because it did not follow a normal distribution. The percentage of patients in each cohort who selected a top-box response for each CG-CAHPS survey item were compared using Fisher exact test. All CG-CAHPS survey items that demonstrated statistically significant differences between depressed and non-depressed cohorts were included in a multivariate logistic regression analysis to determine whether preoperative depression was independently associated with patient satisfaction. Our multivariate regression model adjusted for all patient-level covariates with P < 0.10 on univariate analysis as well improvement in PROMIS-GPH score, as authors deemed this variable to be of clinical significance. All statistical analyses were conducted using IBM SPSS software (version 26.0, IBM Corp.), and statistical significance was defined at the P < 0.05 level.