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


The aim of the present study was to examine the association between preoperative depression, as measured by PHQ-9 score, and patient satisfaction, as measured by postoperative CG-CAHPS survey responses, with the outpatient spine clinic experience after lumbar surgery. Our analysis revealed that patients with preoperative depression were less likely to report top-box ratings for several metrics on the CG-CAHPS survey, even after controlling for patient-level covariates such as age, sex, tobacco use, self-reported overall health, and improvement in PROMIS-GPH score. Specifically, our multivariate analysis showed that depressed patients had lower odds of endorsing satisfaction with two aspects of spine surgeon communication and indicating top-box OPRs for their spine surgeon on the CG-CAHPS survey.

Although previous work has shown that preoperative depression is associated with worse patient-reported outcomes,[8–12] lower satisfaction with outcomes,[12,13] and lower satisfaction with the inpatient hospital experience after lumbar spine surgery,[14] none has utilized CG-CAHPS scores to examine its effect on satisfaction with spine surgeons in the outpatient setting after lumbar surgery. Chapin et al[12] showed that patients with self-reported preoperative depression who underwent lumbar spine surgery were more likely to have worse patient-reported outcomes and experience dissatisfaction with outcomes at 3 and 12 months after surgery. Adogwa et al[13] examined patients receiving revision lumbar surgery for spinal stenosis, and found that patients with higher Zung depression scores were less likely to report satisfaction with postsurgical outcomes at 2-year follow-up, irrespective of changes in pain and disability scores.[24,25] In another study, Levin et al[14] assessed the effect of preoperative depression on inpatient hospital experience, as measured by the HCAHPS survey, in the lumbar fusion population, and found that patients with preoperative depression were more likely to exhibit lower satisfaction with several aspects of their inpatient experience. In particular, patients with preoperative depression felt less respected by physicians and nurses during their inpatient stay, and were less likely to feel that they received help from the inpatient team promptly after requesting it. The present study extends these findings by utilizing CG-CAHPS, a measure of patient experience in the outpatient setting that was developed by CMS and is administered in physician offices nationwide.[24] In showing that preoperative depression independently predicts lower patient satisfaction with spine surgeon communication and, perhaps as a consequence, lower provider ratings for spine surgeons overall, our results provide insights that may help to improve the patient experience in this population and better interpret the results of patient satisfaction surveys developed by CMS.

There is evidence to indicate that affective dysfunction in depression negatively influences interpersonal interactions,[26–28] which are essential to establishing a successful physician-patient relationship. A meta-analysis conducted by Bora and Berk[26] showed that depressed patients are more likely to exhibit deficits in theory of mind, which is the ability to recognize and understand others' intentions and desires during social encounters. Furthermore, patients with depression have been shown to demonstrate increased sensitivity to social rejection and excessive reassurance seeking from social partners.[27,28] These factors may explain why, in our study, depressed patients felt that spine surgeons did not provide understandable explanations and provided lower satisfaction ratings for their spine surgeons overall. Therefore, patient experience for this population may be improved by pretreating depression and/or approaching patient-physician interactions with greater sensitivity to their needs. Two previous studies support the use of these and similar strategies in patients receiving spine surgery.[11,29] Elsamadicy et al[29] showed that pretreatment of depression with antidepressants 6 months before cervical spine surgery improved patient perception of pain and disability outcomes 2 years after surgery. In a prospective study of patients receiving lumbar surgery for spinal stenosis, Sinikallio et al[11] showed that patients whose depression resolved after surgery had similar improvement in patient-reported outcomes to patients without depression. Taken together, these studies suggest that pretreating depression may serve to improve clinical outcomes, and therefore satisfaction, in patients receiving lumbar surgery.

Our study also provides initial evidence to suggest that preoperative depression should be considered when interpreting CG-CAHPS ratings for spine surgeons. At our institution and many others nationwide, survey vendors convert provider-specific CG-CAHPS responses into 5-point star ratings that are publicly reported online.[30] These ratings can then be used by patients when selecting spine surgeons or in physician incentive programs to adjust reimbursement, as performed in the CMS Merit-based Incentive Payment System.[6] Although CMS globally adjusts CG-CAHPS scores for patient age, education level, and self-reported health status to account for variability in case-mix between institutions,[31] there is concern that these adjustments may not adequately account for all patient-level factors that influence satisfaction ratings, particularly across different specialty settings. Our study in the lumbar spine surgery population shows that, even after adjusting for patient-level covariates, preoperative depression independently influences CG-CAHPS ratings contributing to two of six items that are publicly reported for providers at our institution. The results of our study, when taken in conjunction with a growing body of evidence, support further investigation of the impact of depression on patient satisfaction as measured by CMS in other specialty settings. Although additional studies would need to confirm these findings in other patient populations, it may be appropriate for CMS to consider including depression as a variable in case-mix adjustments applied to satisfaction surveys.

The present study has several important limitations. The results of this study may have limited external validity as they were obtained from retrospective review of patients at a single institution. Although our sample demographics may therefore not reflect those at other institutions, we attempted to account for potential demographic differences by adjusting for patient-level covariates in our multivariate model. Another limitation of this study may arise from the manner in which depression was defined. All patients with a preoperative PHQ9 score ≥10 were included in our depressed cohort, irrespective of whether an official diagnosis of depression had been made by a healthcare provider. Although the PHQ-9 may result in high false-positive rates in certain settings, a recent meta-analysis of individual participant data found that a PHQ-9 score ≥10 had excellent sensitivity (88%) and specificity (85%) for detecting major depression when compared with semistructured diagnostic interviews, which closely approximate diagnostic interviews performed by experts.[23] Moreover, the validity of using a PHQ9 score ≥10 in spine surgery patients has been established in prior work.[19] Lastly, our study is unable to establish the directionality of the association between preoperative depression and lower CG-CAHPS scores. While patients with preoperative depression may have lower perceptions of provider treatment, it is also possible that provider treatment of patients with preoperative depression is worse. Future studies with prospective multicenter data should be conducted to further investigate the effect of preoperative depression on CG-CAHPS ratings.

In conclusion, our results indicate that moderate-to-severe preoperative depression is associated with lower patient satisfaction with spine surgeons in the outpatient setting after lumbar spine surgery. Even after controlling for patient-level covariates, preoperative depression was found to independently predict lower CG-CAHPS scores on items pertaining to physician communication and OPR in the outpatient spine clinic. These results add to, and are generally concordant with, a growing body of evidence to suggest that preoperative depression adversely affects patient experience in the lumbar spine surgery population. Future studies should evaluate the effect of depression pretreatment on patient satisfaction and outcomes following lumbar spine surgery.