- Email: [email protected]
Surgical Complications Impact Patient Perception of Hospital Care
Surgical Complications Impact Patient Perception of Hospital Care Brooke H Gurland, MD, FACS, James Merlino, MD, FACS, Tim Sobol, PMP, Patricia Ferreira, Tracy Hull, MD, FACS, Massarat Zutshi, MD, FACS, Ravi P Kiran, MD, FACS
PT,
Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients’ perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems “top-box” (most favorable) scores. STUDY DESIGN: All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and “surgical technique” or “medical.” Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively. RESULTS: One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p ¼ 0.023) irrespective of type of complication (minor vs major; p ¼ 0.72 or technique vs medical; p ¼ 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p ¼ 0.0003) and the type of complication did not influence this assessment (minor vs major; p ¼ 0.71 and technique vs medical; p ¼ 0.95). CONCLUSIONS: The occurrence of any complication after colorectal surgery adversely impacts patients’ selfreported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients’ assessment of quality in the context of variations in patient, disease, and surgical factors is required. (J Am Coll Surg 2013;217:843e849. 2013 by the American College of Surgeons) BACKGROUND:
hospital care experience.4,5 For patients undergoing surgery, the eventual outcomes and recovery after surgery are integral to their care. Because a proportion of patients undergoing surgery are expected to have complications, a risk that is influenced by disease severity and operative complexity despite attempts to provide the best possible medical care, it can be argued that their perception of care is likely influenced by eventual outcomes. Because patients’ perceptions of their care are based on experience, it is possible that postoperative complications negatively impact how patients score the hospital on the HCAHPS survey. The aim of this study was to evaluate this association by comparing HCAHPS responses in subgroups of patients with and without postoperative complications after colorectal surgical procedures.
Health care consumers, payers, and regulatory agencies have become increasingly interested in the quality of health care in the United States.1 The Centers for Medicare and Medicaid Services are using value-based purchasing to link reimbursement to quality of care through “pay for performance” initiatives.2 Quality of surgical care can be measured through process measures, such as the Surgical Care Improvement Program3 or patient-perception questionnaires. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital survey is a standardized instrument and data-collection method developed to measure patients’ perspectives on their Disclosure Information: Nothing to disclose. Received March 31, 2013; Revised May 31, 2013; Accepted June 24, 2013. From the Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH. Correspondence address: Brooke H Gurland, MD, FACS, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, A30, Cleveland, OH 44195. email: [email protected]
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
METHODS This IRB-approved study included patients who underwent colorectal surgery from October 2009 to June
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2012 at a tertiary care, high-volume teaching institution. At out institution, colorectal surgical patients are primarily located on one nursing floor. Surgical complications as defined by the American College of Surgeons NSQIP6 were collected by an experienced physician reviewer from operative reports, discharge summaries, and postoperative clinic and telephone notes. Surgical procedures were grouped into the following categories: major abdominal cases, anorectal procedures, and those related to either stoma creation or stoma closure. Complications were grouped into major and minor events (Table 1). Complications were also divided into 2 groups. The first group included complications that might be Table 1.
Types of Complications
Complications*
Major Anastomotic leak Rectal stump leak Abdominal/pelvic abscess (organ space SSI) Small bowel obstruction Myocardial infarction Pneumonia Thromboembolic events Stroke Acute renal failure Dehiscence or evisceration Reoperative surgery (during the same admission) Intraoperative urinary tract injury Enteric leak Enterotomy Major bleeding Vascular injury Sepsis Minor Urinary tract infection Wound infection Postoperative ileus Transfusions Clostridium difficile colitis Arrythmia Dehydration
Frequencyy n %
10 2 43 27 2 11 42 3 12 4
0.71 0.14 3.0 1.9 0.14 0.78 3.0 0.21 0.85 0.28
32 6 1 7 3 1 14
2.3 0.5 0.08 0.58 0.25 0.08 1.2
44 82 238 111 14 16 19
3.1 5.8 16.9 7.9 1.0 1.3 1.6
Complication data were not available for all patients. One or more complications can be associated with each Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaire. *Complication frequencies are based on the total number of HCAHPS questionnaires. y Numbers are based on the 1,409 HCAHPS questionnaires. One hundred and seventy-six patients completed more than one questionnaire due to readmission or elective second-stage surgery. SSI, surgical site infection.
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perceived by the patient as being directly related to the surgical technique and more controllable by the surgeon, including anastomotic leak, rectal stump leak, abdominal/ pelvic abscess, dehiscence, return to the operating room, urinary tract or vascular injury, enteric leak or enterotomy, major bleeding, and wound infection. On the other hand, complications that might be perceived as less related to surgical technique, and therefore not controllable by the surgeon, were considered medical. These complications included small bowel obstruction, Clostridium difficile colitis, myocardial infarction, pneumonia, thrombolembolic events, stroke, acute renal failure, urinary tract infection, postoperative ileus, and transfusions. We chose to categorize postoperative ileus as a medical complication because return of gastrointestinal function is unpredictable and might not necessarily depend on surgical technique. We chose to categorize C difficile colitis as a minor complication because the majority of cases were self-limited as a result of early detection and treatment. Hospital Consumer Assessment of Healthcare Providers and Systems The HCAHPS survey contains 18 “patient perspectives on care” and “patient rating” items that encompass 8 key topics related to recent hospital stay. This survey has a total of 27 questions that are grouped into the following domains: doctor communication, nurse communication, responsiveness of hospital staff, pain management, communication about medications, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, overall hospital rating, and recommendation of the hospital to others (Fig. 1). Hospital Consumer Assessment of Healthcare Providers and Systems results are publicly reported as “top-box,” “middle-box,” and “bottom-box” scores. The top-box responses are considered the most positive responses to HCAHPS survey questions and are designated as benchmarks for satisfaction. The top-box response is “always” for the 5 HCAHPS questions related to communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medications and cleanliness, and quietness of hospital environment. The response is “yes” for discharge information, 9 or 10 (high) for the overall hospital rating item, and “would definitely recommend” for the recommend the hospital item. The HCAHPS surveys are distributed in our institution by an approved third-party survey vendor. The surveys are administered via standard mail with return envelopes addressed to the vendor. The HCAHPS surveys
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Composite domain 1. Communication with Nurses (Q1, Q2, Q3) 2. Communication with Doctors (Q5, Q6, Q7) 3. Responsiveness of Hospital Staff (Q4, Q11) 4. Pain Management (Q13, Q14) 5. Communication about Medicine (Q16, Q17) 6. Discharge Information (Q19, Q20) Individual domain 1. Cleanliness of Hospital Environment (Q8) 2. Quietness of Hospital Environment (Q9) Global domain 1. Overall Hospital Rating (Q21) 2. Recommend the Hospital (Q22) The Top Box score is the percentage of survey respondents giving the most favorable responses on the measure. Measure Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management
Top Box Responses “Always” “Always” “Always” “Always”
Figure 1. Hospital Consumer Assessment of Healthcare Providers and Systems measures.
are distributed to patients older than 18 years of age with nonpsychiatric diagnosis codes who spent at least 1 night in the hospital and are able to read and speak English. Prisoners, patients with a foreign home address, and those who are discharged to a rehabilitation facility or nursing home are excluded from participating in the survey. A list of all discharged patients is generated and sent to the vendor electronically daily. The vendor identifies qualifying HCAHPS patients from that list according to the Centers for Medicare and Medicaid Services’ guidelines for selection and mails the survey to these patients 5 to 6 days after the date of discharge. Per Centers for Medicare and Medicaid Services’ protocol, a second survey is sent to patients who do not respond the first time. Results are then scored by the vendor and made available to our institution. Medicare then calculates results from individual patient responses and adjusts the raw data based on patient-mix variables, service line, and mode of survey administration before publicizing the results on their website (http://www. hospitalcompare.hhs.gov/). This site contains data on all US hospitals and is updated quarterly. The top-box score for a domain is calculated as the percentage of the topbox responses based on all answered items. Because some patients were readmitted or underwent planned
reoperation, these patients returned more than one HCAHPS survey. Statistical analysis Data are presented as means and SDs. To account for the greater number of returned HCAHPS scores than the total number of patients, proportions for the various characteristics were calculated using the total number of admissions within each group as the denominator, rather than the number of patients. A chi-square test was used to compare binary and Wilcoxon rank sum test and KruskalWallis tests to compare continuous top-box scores between groups. Unless otherwise specified, all tests were performed at a 2-sided significance level of 0.05. Paired comparisons were performed using a Bonferroniadjusted significance level calculated for each domain. All analyses were performed by an experienced statistician using SAS software version 9.2 (SAS Institute).
RESULTS Hospital Consumer Assessment of Healthcare Providers and Systems survey results were available for patients discharged after colorectal surgery between October 2009 and June 2012. During the same time period, adverse
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events were collected on the same patients using standardized definitions for surgical complications. A total of 1,409 HCAHPS surveys were collected on 1,233 patients, mean age was 53.2 (15.69) years. The additional 176 surveys for the 1,233 patients reflect those collected for patients who were either readmitted or scheduled for a second planned inpatient surgery. Demographics are listed in Table 2. Patient characteristics and Hospital Consumer Assessment of Healthcare Providers and Systems responses Although female patients were more likely to report top-box responses about quietness of the hospital (p ¼ 0.016), male patients reported higher scores for communication about medications (p ¼ 0.001). There were no other sex differences for the domains related to Table 2.
Demographics and Patient Characteristics
Variables
Age, y, mean SD Sex, n (%) Female Male Ethnicity, n (%) Caucasian African American Other Marital status, n (%) Married Single Divorced Legally separated Widowed Unknown Education, n (%) *No high school Some high school High school graduation Some college 4-year college graduation More than 4 years of college No response Overall quality of health, n (%) *No response Poor Fair Good Very good Excellent
53.23 15.69 743 (52.7) 666 (47.3) 1,332 (94.5) 46 (3.3) 31 (2.2) 509 191 55 4 38 612
(36.1) (13.6) (3.9) (0.28) (7.2) (43.4)
7 46 379 441 253 262 21
(.4) (3.3) (27.3) (31.8) (18.2) (18.9) (1.4)
15 45 237 540 450 122
(1.1) (3.2) (17) (38.7) (32.3) (8.8)
*No response, patient did not provide a response to this question.
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communication with nurses or doctors, staff responsiveness, pain management, discharge, overall hospital rating, recommendation, or cleanliness. When evaluating the association between patient race and the HCAHPS responses, Caucasian patients were more likely to recommend the hospital (Caucasian 86% vs black 70%; p ¼ 0.004). Race did not otherwise impact the other domain scores. Married patients reported more top-box scores for pain management (p ¼ 0.049) and discharge (p ¼ 0.017). English was the predominant language of responders (n ¼ 1,223), with no differences in scores noted for patients who reported English as a second language. Patients who perceived their overall health as excellent, very good, or good had significantly higher scores related to hospital rating (p < 0.001), hospital recommendation (p < 0.001), cleanliness (p < 0.001), communication with nurses (p < 0.001), pain management (p < 0.001), and communication about medication (p < 0.0001) when compared with those patients who reported fair or poor health. Patients with some college education were more likely to recommend the hospital than high school graduates (89% vs 82%; p ¼ 0.008). However, education did not impact other domain scores. Procedures Surgical procedures were grouped as major abdominal (n ¼ 955 [67.8%]), anorectal (n ¼ 114 [8.1%]), and stoma related (n ¼ 340 [24.1%]). Patients who underwent abdominal surgery were more likely to report higher overall hospital rating scores of 9 or 10 than patients undergoing anorectal surgery (81% vs 70%; p ¼ 0.01). Patients undergoing abdominal procedures also reported better nurse and doctor communication scores (p ¼ 0.04 and p ¼ 0.004, respectively). Complications The frequency and type of the individual complications are reported in Table 1. More than one type of complication might have developed in a patient during each admission. Overall median length of stay was 6 days (interquartile range 4 to 9 days). Length of stay was greater for patients who developed a complication than for those who did not (p < 0.001) and for patients who had major rather than minor complications (p < 0.001). Length of stay was also greater for patients with medical rather than technique-related complications (p < 0.001). Patients without any complications were more likely to report “definitely yes” with regard to whether they would recommend the hospital to others compared with those with complications (p ¼ 0.023), irrespective of the type of complication (minor vs major; p ¼ 0.72 or technique vs medical; p ¼ 0.5) (Table 3).
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Table 3.
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Comparison of No Complications vs Any Complications for Patients with “Top Box” Responses
Variable
Length of stay Communication with nurse* Communication with doctor* Responsiveness of hospital staff* Pain management* Communication about medicine* Discharge information* Cleanliness “always”y Quietness “always”y Overall rating >9y Recommendation “definitely yes”y
No complications (n ¼ 926) Available, n Mean SD/n (%)
926 926 924 908 872 504 882 919 920 901 924
5.3 4.09 0.82 0.31 0.8 0.34 0.61 0.47 0.72 0.38 0.64 0.36 0.92 0.2 588 (64) 425 (46) 717 (80) 806 (87)
Complication (n ¼ 483) Available, n Mean SD/n (%)
482 483 483 479 452 337 454 479 477 475 481
10.9 6.57 0.78 0.35 0.77 0.35 0.51 0.47 0.69 0.4 0.65 0.39 0.94 0.18 288 (60) 179 (38) 369 (78) 398 (83)
p Value
<0.0001 0.091 0.086 0.0003 0.22 0.35 0.042 0.16 0.002 0.41 0.023
*Continuous domains top box score. p values were from Wilcoxon-rank-sum tests. y Categorical domains top box. p values were from chi-square tests.
Patients without any complications were more likely to report top-box “always” responses to the question related to the responsiveness of hospital staff (p ¼ 0.0003) when compared with those with complications, regardless of the type of complication (minor vs major; p ¼ 0.71 or technique vs medical; p ¼ 0.95). Patients with medical complications reported higher top-box responses for discharge when compared with those with technique complications (p ¼ 0.026).
DISCUSSION Value-based purchasing is designed to compensate health care providers based on the quality of care instead of the volume of procedures or treatments. The HCAHPS survey was developed to assess patient perceptions of inpatient quality of care. Hospital Consumer Assessment of Healthcare Providers and Systems provides comparable data among hospitals that are then made available to payers, as well as for public analysis. Despite the increasing use of such measures, there is no consensus about the legitimacy of patient scores as a measure of technical care. There is a paucity of data evaluating HCAHPS as a measure of patient satisfaction for surgical procedures and the impact of surgical complications on HCAHP domain scores. In this study, we hypothesized that the presence of surgical complications would impact the patients’ perception of their hospital care. We demonstrated that the occurrence of surgical complications impacted 2 of the 10 HCAHPS domains. Patients without any complications were more likely to report “definitely yes” for recommendation of the hospital and to report “always” for responsiveness of hospital staff. A patient with an uncomplicated course is likely to be happy with his or her outcomes and these
findings might well be expected. Patients with complications were less likely to recommend the hospital. Considering that patients with postoperative complications require the greatest attention and resources, the finding that a lower proportion of this group reported “always” to the responsiveness of hospital staff is surprising. Responsiveness is measured on HCAHPS as a composite score that includes the following questions: “(Q4): During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” and “(Q11) How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?” Timeliness of assistance by hospital personnel was reported at only 51% in patients with complications in our cohort. It is possible that patients with complications have more physical limitations requiring dependency on the hospital support staff, which might explain the statistically lower responses in this group. Patients with complications also reported lower scores for hospital quietness and lower global domain responses for hospital recommendation. Boulding and colleagues analyzed factors influencing global patient-experience scores and found that nursing communication was rated the highest, followed by pain management and responsiveness.7 It is possible that the low responsiveness scores in our population were responsible for the lower global scores. Woolley and colleagues previously suggested that both the expectation of certain outcomes, as well as the level of communication between the patient and provider about the expected outcomes, contribute to patient satisfaction.8 Providing additional support and attention to patients with complications might have improved patients’ perception of care and provides an area for quality improvement. The relationship between patient perception of care and technical care has been debated. Jha and colleagues found
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that HCAHPS scores correlated positively with clinical adherence to treatment guidelines for acute myocardial infarction, congestive heart failure, pneumonia, and surgery.9 The mean Hospital Quality Alliance score for surgery was 85.7% for hospitals in the top quartile of HCAHPS ratings compared with 82.8% for hospitals at the bottom quartile (p < 0.001).9 Isaac and colleagues10 correlated HCAHPS scores from 800 hospitals with Surgical Patient Safety Indicators, such as postoperative hemorrhage, respiratory failure, pulmonary embolism or deep venous thrombosis, and postoperative sepsis. Better performance for respiratory failure and pulmonary embolism/deep venous thrombosis were associated with better performance in 5 HCAHPS composites. Boulding and colleagues reported lower 30-day risk-adjusted readmission rates for patients with higher overall satisfaction and satisfaction with discharge planning.7 Manary and colleagues concurred that patient satisfaction correlates with clinical outcomes and that higher scores reflect a patient’s “sense” of technical care.11 The occurrence of a complication after surgery might be expected to negatively impact a patient’s desired outcomes. Because severity and type of complication can vary and are expected to influence outcomes, and therefore responses, we chose to categorize the complications as major and minor based on traditional methods of reporting in the literature, which depend on the expected long-term impact and potential morbidity to the patient. Complications were also divided into those that we believed patients might perceive as being directly related to the procedure and those that are likely to be considered indirectly related to the surgery, and therefore less controllable by the surgeon. When divided into these subgroups, the perception of care as defined by HCAHPS was not significant. The presence of any type of complication, even those complications with minimal long-term impact, influenced patient-survey responses. Patient-reported health care experiences have previously been reported as influenced by patient characteristics, such as, age, race/ethnicity, education level, and health status.4,12 Our findings similarly suggest that patients who perceived their own health to be poor or fair reported lower global domain scores (p < 0.001) and lower scores for communication with nurses (p < 0.001), pain management (p < 0.001), communication about medication (p < 0.001), and cleanliness (p < 0.001). It appears that patients who reported poor health before their hospitalization need more support and have greater expectations about their hospital experience. The findings of this study suggest that patient perception of care as detected by HCAHPS is influenced by several patient factors, as well as the occurrence of complications. Focusing attention on these groups by
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educating and counseling them in a way that incorporates a thorough discussion of anticipated outcomes will likely produce more realistic expectations. Because patients in whom complications develop after surgery are likely sicker, there is a clinical need for greater attention to their care. An increased responsiveness to their needs will likely improve patient satisfaction and therefore HCAHPS scores. One of the strengths of this study is the availability of HCAHPS and complications data for a large number of colorectal surgery patients. The majority of colorectal surgery patients were in one location, eliminating the bias associated with particular nursing units. Standardized definitions were used for complications, which were carefully stratified based on severity and type. However, categorization of these complications can be subjective. The inclusion of patients selected from a single tertiary care institution that deals with the most complex colorectal disorders is another potential limitation. Patients either choose our facility or are referred by other surgeons based on institutional reputation. Patients might possess a more passive attitude with the belief that they have received the best care and then be more accepting when surgical complications occur; conversely, they might be even less inclined to accept complications. Stoma construction could also potentially affect a colorectal patient’s perception of quality of care. We were unable to evaluate this association due to the small numbers of patients with a primary procedure related to stoma creation. Lastly, as with any survey, a response bias can be expected and only certain types of patients might have returned questionnaires.
CONCLUSIONS In this new era of government-sponsored, value-based health care, consumers are empowered to hold health care providers accountable for both cost and quality of care. The occurrence of any type of complication after colorectal surgery adversely impacts patients’ selfreported perceptions of their hospital care as measured by the HCAHPS survey. Although minimizing and eliminating postoperative complications is ideal and desirable, a proportion of these complications might be inevitable. Strategies aimed at reducing patient risks; educating patients about the possibility of complications; counseling when adverse events do occur; and improving hospital responsiveness to patients with complications, who therefore require the most care, can improve patient experience and satisfaction. In addition, metrics that hold hospitals accountable for reimbursement need to be robust. Variables such as surgical complications that can negatively
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impact patient’s perceptions of their care must be collected and used to appropriately adjust the data. Author Contributions Study conception and design: Gurland, Merlino, Sobol, Zutshi, Kiran Acquisition of data: Gurland, Ferreira Analysis and interpretation of data: Gurland, Merlino, Sobol, Ferreira, Kiran Drafting of manuscript: Gurland, Merlino, Sobol, Ferreira, Hull, Kiran Critical revision: Gurland, Merlino, Sobol, Hull, Zutshi, Kiran Acknowledgment: We would like to thank Daniel Bokar and Carmen Kestranek for data queries and HCAHPS results, and Zhiyuan Sun for the statistical analysis of this study.
4. 5. 6.
7.
8. 9.
REFERENCES 1. Conway PH. Value-driven health care: implications for hospitals and hospitalists. J Hosp Med 2009;4:507e511. 2. Charland K. Pay for performance comes to Medicare in 2009. Healthc Financ Manage 2007;61:60e64. 3. Centers for Medicare and Medicaid Services, Department of Health and Human Services. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective
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payment system annual payment update programdHCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule. Fed Regist 2006;71[226]:67959e68401. Elliott MN, Lehrman WG, Goldstein E, et al. Do hospitals rank differently on HCAHPS for different patient subgroups? Med Care Res Rev 2010;67:56e73. Giordano LA, Elliott MN, Goldstein E, et al. Development, implementation, and public reporting of the HCAHPS survey. Med Care Res Rev 2010;67:27e37. Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg 1998;228:491e507. Boulding W, Glickman SW, Manary MP, et al. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care 2011;17:41e48. Woolley FR, Kane RL, Hughes CC, Wright DD. The effects of doctorpatient communication on satisfaction and outcome of care. Soc Sci Med 1978;12:123e128. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med 2008;359: 1921e1931. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Services Research 2010; 45:1024e1040. doi: 10.1111/j.1475-6773.2010.01122.x. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med 2013;368:201e203. Goldstein E, Elliott MN, Lehrman WG, et al. Racial/ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Med Care Res Rev 2010;67:74e92.
PT,
Public reporting of the Hospital Consumer Assessment of Healthcare Providers and Systems survey is designed to produce data on patients’ perceptions of the quality of hospital care. The aim of this study was to assess the impact of complications on patient responses to Hospital Consumer Assessment of Healthcare Providers and Systems “top-box” (most favorable) scores. STUDY DESIGN: All patients who underwent a colorectal procedure from October 2009 to June 2012 at a single center were included. Patient complications were categorized as major, minor, or no complications and “surgical technique” or “medical.” Chi-square and Wilcoxon rank sum tests were used to compare binary and ordinal top-box scores, respectively. RESULTS: One thousand four hundred and nine surveys were collected for 1,233 patients (mean age 53 15.7 years; 701 [52.2%] females) who underwent 955 (67.8%) major abdominal, 114 (8.1%) anorectal, and 340 (24.1%) stoma-related operations. There were 195 (13.8%) major and 396 (28.1%) minor complications. There were 159 (11.3%) technique complications and 411 (29.2%) medical complications. Patients without any complications were more likely to recommend the hospital than those with complications (p ¼ 0.023) irrespective of type of complication (minor vs major; p ¼ 0.72 or technique vs medical; p ¼ 0.5). Responsiveness of hospital staff was also reported as higher for patients without complications (p ¼ 0.0003) and the type of complication did not influence this assessment (minor vs major; p ¼ 0.71 and technique vs medical; p ¼ 0.95). CONCLUSIONS: The occurrence of any complication after colorectal surgery adversely impacts patients’ selfreported perceptions of hospital care as measured by Hospital Consumer Assessment of Healthcare Providers and Systems. An instrument that more accurately reflects patients’ assessment of quality in the context of variations in patient, disease, and surgical factors is required. (J Am Coll Surg 2013;217:843e849. 2013 by the American College of Surgeons) BACKGROUND:
hospital care experience.4,5 For patients undergoing surgery, the eventual outcomes and recovery after surgery are integral to their care. Because a proportion of patients undergoing surgery are expected to have complications, a risk that is influenced by disease severity and operative complexity despite attempts to provide the best possible medical care, it can be argued that their perception of care is likely influenced by eventual outcomes. Because patients’ perceptions of their care are based on experience, it is possible that postoperative complications negatively impact how patients score the hospital on the HCAHPS survey. The aim of this study was to evaluate this association by comparing HCAHPS responses in subgroups of patients with and without postoperative complications after colorectal surgical procedures.
Health care consumers, payers, and regulatory agencies have become increasingly interested in the quality of health care in the United States.1 The Centers for Medicare and Medicaid Services are using value-based purchasing to link reimbursement to quality of care through “pay for performance” initiatives.2 Quality of surgical care can be measured through process measures, such as the Surgical Care Improvement Program3 or patient-perception questionnaires. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital survey is a standardized instrument and data-collection method developed to measure patients’ perspectives on their Disclosure Information: Nothing to disclose. Received March 31, 2013; Revised May 31, 2013; Accepted June 24, 2013. From the Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH. Correspondence address: Brooke H Gurland, MD, FACS, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, A30, Cleveland, OH 44195. email: [email protected]
ª 2013 by the American College of Surgeons Published by Elsevier Inc.
METHODS This IRB-approved study included patients who underwent colorectal surgery from October 2009 to June
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ISSN 1072-7515/13/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2013.06.015
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2012 at a tertiary care, high-volume teaching institution. At out institution, colorectal surgical patients are primarily located on one nursing floor. Surgical complications as defined by the American College of Surgeons NSQIP6 were collected by an experienced physician reviewer from operative reports, discharge summaries, and postoperative clinic and telephone notes. Surgical procedures were grouped into the following categories: major abdominal cases, anorectal procedures, and those related to either stoma creation or stoma closure. Complications were grouped into major and minor events (Table 1). Complications were also divided into 2 groups. The first group included complications that might be Table 1.
Types of Complications
Complications*
Major Anastomotic leak Rectal stump leak Abdominal/pelvic abscess (organ space SSI) Small bowel obstruction Myocardial infarction Pneumonia Thromboembolic events Stroke Acute renal failure Dehiscence or evisceration Reoperative surgery (during the same admission) Intraoperative urinary tract injury Enteric leak Enterotomy Major bleeding Vascular injury Sepsis Minor Urinary tract infection Wound infection Postoperative ileus Transfusions Clostridium difficile colitis Arrythmia Dehydration
Frequencyy n %
10 2 43 27 2 11 42 3 12 4
0.71 0.14 3.0 1.9 0.14 0.78 3.0 0.21 0.85 0.28
32 6 1 7 3 1 14
2.3 0.5 0.08 0.58 0.25 0.08 1.2
44 82 238 111 14 16 19
3.1 5.8 16.9 7.9 1.0 1.3 1.6
Complication data were not available for all patients. One or more complications can be associated with each Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaire. *Complication frequencies are based on the total number of HCAHPS questionnaires. y Numbers are based on the 1,409 HCAHPS questionnaires. One hundred and seventy-six patients completed more than one questionnaire due to readmission or elective second-stage surgery. SSI, surgical site infection.
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perceived by the patient as being directly related to the surgical technique and more controllable by the surgeon, including anastomotic leak, rectal stump leak, abdominal/ pelvic abscess, dehiscence, return to the operating room, urinary tract or vascular injury, enteric leak or enterotomy, major bleeding, and wound infection. On the other hand, complications that might be perceived as less related to surgical technique, and therefore not controllable by the surgeon, were considered medical. These complications included small bowel obstruction, Clostridium difficile colitis, myocardial infarction, pneumonia, thrombolembolic events, stroke, acute renal failure, urinary tract infection, postoperative ileus, and transfusions. We chose to categorize postoperative ileus as a medical complication because return of gastrointestinal function is unpredictable and might not necessarily depend on surgical technique. We chose to categorize C difficile colitis as a minor complication because the majority of cases were self-limited as a result of early detection and treatment. Hospital Consumer Assessment of Healthcare Providers and Systems The HCAHPS survey contains 18 “patient perspectives on care” and “patient rating” items that encompass 8 key topics related to recent hospital stay. This survey has a total of 27 questions that are grouped into the following domains: doctor communication, nurse communication, responsiveness of hospital staff, pain management, communication about medications, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, overall hospital rating, and recommendation of the hospital to others (Fig. 1). Hospital Consumer Assessment of Healthcare Providers and Systems results are publicly reported as “top-box,” “middle-box,” and “bottom-box” scores. The top-box responses are considered the most positive responses to HCAHPS survey questions and are designated as benchmarks for satisfaction. The top-box response is “always” for the 5 HCAHPS questions related to communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medications and cleanliness, and quietness of hospital environment. The response is “yes” for discharge information, 9 or 10 (high) for the overall hospital rating item, and “would definitely recommend” for the recommend the hospital item. The HCAHPS surveys are distributed in our institution by an approved third-party survey vendor. The surveys are administered via standard mail with return envelopes addressed to the vendor. The HCAHPS surveys
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Composite domain 1. Communication with Nurses (Q1, Q2, Q3) 2. Communication with Doctors (Q5, Q6, Q7) 3. Responsiveness of Hospital Staff (Q4, Q11) 4. Pain Management (Q13, Q14) 5. Communication about Medicine (Q16, Q17) 6. Discharge Information (Q19, Q20) Individual domain 1. Cleanliness of Hospital Environment (Q8) 2. Quietness of Hospital Environment (Q9) Global domain 1. Overall Hospital Rating (Q21) 2. Recommend the Hospital (Q22) The Top Box score is the percentage of survey respondents giving the most favorable responses on the measure. Measure Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management
Top Box Responses “Always” “Always” “Always” “Always”
Figure 1. Hospital Consumer Assessment of Healthcare Providers and Systems measures.
are distributed to patients older than 18 years of age with nonpsychiatric diagnosis codes who spent at least 1 night in the hospital and are able to read and speak English. Prisoners, patients with a foreign home address, and those who are discharged to a rehabilitation facility or nursing home are excluded from participating in the survey. A list of all discharged patients is generated and sent to the vendor electronically daily. The vendor identifies qualifying HCAHPS patients from that list according to the Centers for Medicare and Medicaid Services’ guidelines for selection and mails the survey to these patients 5 to 6 days after the date of discharge. Per Centers for Medicare and Medicaid Services’ protocol, a second survey is sent to patients who do not respond the first time. Results are then scored by the vendor and made available to our institution. Medicare then calculates results from individual patient responses and adjusts the raw data based on patient-mix variables, service line, and mode of survey administration before publicizing the results on their website (http://www. hospitalcompare.hhs.gov/). This site contains data on all US hospitals and is updated quarterly. The top-box score for a domain is calculated as the percentage of the topbox responses based on all answered items. Because some patients were readmitted or underwent planned
reoperation, these patients returned more than one HCAHPS survey. Statistical analysis Data are presented as means and SDs. To account for the greater number of returned HCAHPS scores than the total number of patients, proportions for the various characteristics were calculated using the total number of admissions within each group as the denominator, rather than the number of patients. A chi-square test was used to compare binary and Wilcoxon rank sum test and KruskalWallis tests to compare continuous top-box scores between groups. Unless otherwise specified, all tests were performed at a 2-sided significance level of 0.05. Paired comparisons were performed using a Bonferroniadjusted significance level calculated for each domain. All analyses were performed by an experienced statistician using SAS software version 9.2 (SAS Institute).
RESULTS Hospital Consumer Assessment of Healthcare Providers and Systems survey results were available for patients discharged after colorectal surgery between October 2009 and June 2012. During the same time period, adverse
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events were collected on the same patients using standardized definitions for surgical complications. A total of 1,409 HCAHPS surveys were collected on 1,233 patients, mean age was 53.2 (15.69) years. The additional 176 surveys for the 1,233 patients reflect those collected for patients who were either readmitted or scheduled for a second planned inpatient surgery. Demographics are listed in Table 2. Patient characteristics and Hospital Consumer Assessment of Healthcare Providers and Systems responses Although female patients were more likely to report top-box responses about quietness of the hospital (p ¼ 0.016), male patients reported higher scores for communication about medications (p ¼ 0.001). There were no other sex differences for the domains related to Table 2.
Demographics and Patient Characteristics
Variables
Age, y, mean SD Sex, n (%) Female Male Ethnicity, n (%) Caucasian African American Other Marital status, n (%) Married Single Divorced Legally separated Widowed Unknown Education, n (%) *No high school Some high school High school graduation Some college 4-year college graduation More than 4 years of college No response Overall quality of health, n (%) *No response Poor Fair Good Very good Excellent
53.23 15.69 743 (52.7) 666 (47.3) 1,332 (94.5) 46 (3.3) 31 (2.2) 509 191 55 4 38 612
(36.1) (13.6) (3.9) (0.28) (7.2) (43.4)
7 46 379 441 253 262 21
(.4) (3.3) (27.3) (31.8) (18.2) (18.9) (1.4)
15 45 237 540 450 122
(1.1) (3.2) (17) (38.7) (32.3) (8.8)
*No response, patient did not provide a response to this question.
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communication with nurses or doctors, staff responsiveness, pain management, discharge, overall hospital rating, recommendation, or cleanliness. When evaluating the association between patient race and the HCAHPS responses, Caucasian patients were more likely to recommend the hospital (Caucasian 86% vs black 70%; p ¼ 0.004). Race did not otherwise impact the other domain scores. Married patients reported more top-box scores for pain management (p ¼ 0.049) and discharge (p ¼ 0.017). English was the predominant language of responders (n ¼ 1,223), with no differences in scores noted for patients who reported English as a second language. Patients who perceived their overall health as excellent, very good, or good had significantly higher scores related to hospital rating (p < 0.001), hospital recommendation (p < 0.001), cleanliness (p < 0.001), communication with nurses (p < 0.001), pain management (p < 0.001), and communication about medication (p < 0.0001) when compared with those patients who reported fair or poor health. Patients with some college education were more likely to recommend the hospital than high school graduates (89% vs 82%; p ¼ 0.008). However, education did not impact other domain scores. Procedures Surgical procedures were grouped as major abdominal (n ¼ 955 [67.8%]), anorectal (n ¼ 114 [8.1%]), and stoma related (n ¼ 340 [24.1%]). Patients who underwent abdominal surgery were more likely to report higher overall hospital rating scores of 9 or 10 than patients undergoing anorectal surgery (81% vs 70%; p ¼ 0.01). Patients undergoing abdominal procedures also reported better nurse and doctor communication scores (p ¼ 0.04 and p ¼ 0.004, respectively). Complications The frequency and type of the individual complications are reported in Table 1. More than one type of complication might have developed in a patient during each admission. Overall median length of stay was 6 days (interquartile range 4 to 9 days). Length of stay was greater for patients who developed a complication than for those who did not (p < 0.001) and for patients who had major rather than minor complications (p < 0.001). Length of stay was also greater for patients with medical rather than technique-related complications (p < 0.001). Patients without any complications were more likely to report “definitely yes” with regard to whether they would recommend the hospital to others compared with those with complications (p ¼ 0.023), irrespective of the type of complication (minor vs major; p ¼ 0.72 or technique vs medical; p ¼ 0.5) (Table 3).
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Table 3.
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Comparison of No Complications vs Any Complications for Patients with “Top Box” Responses
Variable
Length of stay Communication with nurse* Communication with doctor* Responsiveness of hospital staff* Pain management* Communication about medicine* Discharge information* Cleanliness “always”y Quietness “always”y Overall rating >9y Recommendation “definitely yes”y
No complications (n ¼ 926) Available, n Mean SD/n (%)
926 926 924 908 872 504 882 919 920 901 924
5.3 4.09 0.82 0.31 0.8 0.34 0.61 0.47 0.72 0.38 0.64 0.36 0.92 0.2 588 (64) 425 (46) 717 (80) 806 (87)
Complication (n ¼ 483) Available, n Mean SD/n (%)
482 483 483 479 452 337 454 479 477 475 481
10.9 6.57 0.78 0.35 0.77 0.35 0.51 0.47 0.69 0.4 0.65 0.39 0.94 0.18 288 (60) 179 (38) 369 (78) 398 (83)
p Value
<0.0001 0.091 0.086 0.0003 0.22 0.35 0.042 0.16 0.002 0.41 0.023
*Continuous domains top box score. p values were from Wilcoxon-rank-sum tests. y Categorical domains top box. p values were from chi-square tests.
Patients without any complications were more likely to report top-box “always” responses to the question related to the responsiveness of hospital staff (p ¼ 0.0003) when compared with those with complications, regardless of the type of complication (minor vs major; p ¼ 0.71 or technique vs medical; p ¼ 0.95). Patients with medical complications reported higher top-box responses for discharge when compared with those with technique complications (p ¼ 0.026).
DISCUSSION Value-based purchasing is designed to compensate health care providers based on the quality of care instead of the volume of procedures or treatments. The HCAHPS survey was developed to assess patient perceptions of inpatient quality of care. Hospital Consumer Assessment of Healthcare Providers and Systems provides comparable data among hospitals that are then made available to payers, as well as for public analysis. Despite the increasing use of such measures, there is no consensus about the legitimacy of patient scores as a measure of technical care. There is a paucity of data evaluating HCAHPS as a measure of patient satisfaction for surgical procedures and the impact of surgical complications on HCAHP domain scores. In this study, we hypothesized that the presence of surgical complications would impact the patients’ perception of their hospital care. We demonstrated that the occurrence of surgical complications impacted 2 of the 10 HCAHPS domains. Patients without any complications were more likely to report “definitely yes” for recommendation of the hospital and to report “always” for responsiveness of hospital staff. A patient with an uncomplicated course is likely to be happy with his or her outcomes and these
findings might well be expected. Patients with complications were less likely to recommend the hospital. Considering that patients with postoperative complications require the greatest attention and resources, the finding that a lower proportion of this group reported “always” to the responsiveness of hospital staff is surprising. Responsiveness is measured on HCAHPS as a composite score that includes the following questions: “(Q4): During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” and “(Q11) How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?” Timeliness of assistance by hospital personnel was reported at only 51% in patients with complications in our cohort. It is possible that patients with complications have more physical limitations requiring dependency on the hospital support staff, which might explain the statistically lower responses in this group. Patients with complications also reported lower scores for hospital quietness and lower global domain responses for hospital recommendation. Boulding and colleagues analyzed factors influencing global patient-experience scores and found that nursing communication was rated the highest, followed by pain management and responsiveness.7 It is possible that the low responsiveness scores in our population were responsible for the lower global scores. Woolley and colleagues previously suggested that both the expectation of certain outcomes, as well as the level of communication between the patient and provider about the expected outcomes, contribute to patient satisfaction.8 Providing additional support and attention to patients with complications might have improved patients’ perception of care and provides an area for quality improvement. The relationship between patient perception of care and technical care has been debated. Jha and colleagues found
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that HCAHPS scores correlated positively with clinical adherence to treatment guidelines for acute myocardial infarction, congestive heart failure, pneumonia, and surgery.9 The mean Hospital Quality Alliance score for surgery was 85.7% for hospitals in the top quartile of HCAHPS ratings compared with 82.8% for hospitals at the bottom quartile (p < 0.001).9 Isaac and colleagues10 correlated HCAHPS scores from 800 hospitals with Surgical Patient Safety Indicators, such as postoperative hemorrhage, respiratory failure, pulmonary embolism or deep venous thrombosis, and postoperative sepsis. Better performance for respiratory failure and pulmonary embolism/deep venous thrombosis were associated with better performance in 5 HCAHPS composites. Boulding and colleagues reported lower 30-day risk-adjusted readmission rates for patients with higher overall satisfaction and satisfaction with discharge planning.7 Manary and colleagues concurred that patient satisfaction correlates with clinical outcomes and that higher scores reflect a patient’s “sense” of technical care.11 The occurrence of a complication after surgery might be expected to negatively impact a patient’s desired outcomes. Because severity and type of complication can vary and are expected to influence outcomes, and therefore responses, we chose to categorize the complications as major and minor based on traditional methods of reporting in the literature, which depend on the expected long-term impact and potential morbidity to the patient. Complications were also divided into those that we believed patients might perceive as being directly related to the procedure and those that are likely to be considered indirectly related to the surgery, and therefore less controllable by the surgeon. When divided into these subgroups, the perception of care as defined by HCAHPS was not significant. The presence of any type of complication, even those complications with minimal long-term impact, influenced patient-survey responses. Patient-reported health care experiences have previously been reported as influenced by patient characteristics, such as, age, race/ethnicity, education level, and health status.4,12 Our findings similarly suggest that patients who perceived their own health to be poor or fair reported lower global domain scores (p < 0.001) and lower scores for communication with nurses (p < 0.001), pain management (p < 0.001), communication about medication (p < 0.001), and cleanliness (p < 0.001). It appears that patients who reported poor health before their hospitalization need more support and have greater expectations about their hospital experience. The findings of this study suggest that patient perception of care as detected by HCAHPS is influenced by several patient factors, as well as the occurrence of complications. Focusing attention on these groups by
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educating and counseling them in a way that incorporates a thorough discussion of anticipated outcomes will likely produce more realistic expectations. Because patients in whom complications develop after surgery are likely sicker, there is a clinical need for greater attention to their care. An increased responsiveness to their needs will likely improve patient satisfaction and therefore HCAHPS scores. One of the strengths of this study is the availability of HCAHPS and complications data for a large number of colorectal surgery patients. The majority of colorectal surgery patients were in one location, eliminating the bias associated with particular nursing units. Standardized definitions were used for complications, which were carefully stratified based on severity and type. However, categorization of these complications can be subjective. The inclusion of patients selected from a single tertiary care institution that deals with the most complex colorectal disorders is another potential limitation. Patients either choose our facility or are referred by other surgeons based on institutional reputation. Patients might possess a more passive attitude with the belief that they have received the best care and then be more accepting when surgical complications occur; conversely, they might be even less inclined to accept complications. Stoma construction could also potentially affect a colorectal patient’s perception of quality of care. We were unable to evaluate this association due to the small numbers of patients with a primary procedure related to stoma creation. Lastly, as with any survey, a response bias can be expected and only certain types of patients might have returned questionnaires.
CONCLUSIONS In this new era of government-sponsored, value-based health care, consumers are empowered to hold health care providers accountable for both cost and quality of care. The occurrence of any type of complication after colorectal surgery adversely impacts patients’ selfreported perceptions of their hospital care as measured by the HCAHPS survey. Although minimizing and eliminating postoperative complications is ideal and desirable, a proportion of these complications might be inevitable. Strategies aimed at reducing patient risks; educating patients about the possibility of complications; counseling when adverse events do occur; and improving hospital responsiveness to patients with complications, who therefore require the most care, can improve patient experience and satisfaction. In addition, metrics that hold hospitals accountable for reimbursement need to be robust. Variables such as surgical complications that can negatively
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impact patient’s perceptions of their care must be collected and used to appropriately adjust the data. Author Contributions Study conception and design: Gurland, Merlino, Sobol, Zutshi, Kiran Acquisition of data: Gurland, Ferreira Analysis and interpretation of data: Gurland, Merlino, Sobol, Ferreira, Kiran Drafting of manuscript: Gurland, Merlino, Sobol, Ferreira, Hull, Kiran Critical revision: Gurland, Merlino, Sobol, Hull, Zutshi, Kiran Acknowledgment: We would like to thank Daniel Bokar and Carmen Kestranek for data queries and HCAHPS results, and Zhiyuan Sun for the statistical analysis of this study.
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