Older adult patient satisfaction with brain health exams prior to surgery

Abstract

This study examines patient satisfaction with a novel preoperative neuropsychology program at the University of Florida Hospital (UF Health), the Perioperative Cognitive Anesthesia Network (PeCAN^SM). The PeCAN clinic serves patients 65 and older planning elective surgeries at UF Health by offering brain health exams to establish baseline functioning and to identify cognitive vulnerabilities preoperatively. Patient satisfaction with the program was assessed anonymously with two separate surveys: a brief PeCAN-specific mail-in survey and an electronic general behavioral health survey. Respondents rated their experience with PeCAN on both surveys and had the option to include comments. Mean survey ratings show that patients were satisfied (A- or B-rating on an A-to-F scale) with their overall care (95 %), scheduling experience (93 %), assessment experience (95 %), and clinician feedback recommendations (90 %). Comments were examined to determine general satisfaction with the PeCAN program as well as specific themes in patient experiences. Qualitative analyses indicated that the PeCAN visit was helpful, informative, and valuable to patients’ care.

1. Introduction

1.1. Problem

Over 50 % of surgeries are performed on adults 65 and older, and these patients need special cognitive considerations due to their increased risk for postoperative cognitive complications.^1,2 In response to this need, the American College of Surgeons and American Geriatrics Society updated their best practice guidelines in 2019 to recommend preoperative cognitive evaluations.^3,4 Regardless, neurocognitive consults are not standard requests in perioperative settings, even for individuals with neurodegenerative diseases, depression, or worried-well adults concerned about potential memory loss or delirium after surgery. Neurocognitive consults help identify patients with the highest cognitive vulnerability and can facilitate personalization of perioperative care – including modification of anesthetic regimens and sparing of opioids – for these patients, thus decreasing their risk of developing postoperative cognitive complications, such as delirium.⁵

1.2. Background

The Perioperative Cognitive Anesthesia Network (PeCAN^SM) is a UF Health hospital program providing brain health exams to older adults prior to surgeries. Based on current research in the field of perioperative medicine, neuropsychologists identify cognitive, psychological, and medical risk factors for delirium and postoperative progressive cognitive change and communicate this information to the surgical care team.^6,7 PeCAN was established based on feasibility studies and patient stakeholders supporting the value of preoperative cognitive considerations in a hospital setting.^8–11

The PeCAN program is a phased evaluation designed to allow universal capture of outpatients and in-depth evaluation of at-risk individuals. At UF Health, every patient considered to be at elevated risk of surgical complications – which includes every patient 65 and older – is seen for a preoperative evaluation at the Presurgical Center (PSC). Patients planning any type of surgical procedure requiring anesthesia are eligible for this evaluation, from minimally invasive procedures such as cataract removal to highly invasive procedures such as aortic valve replacement. Recently published data indicated that approximately 41% of surgeries performed on older adults at UF Health are inpatient procedures, however, this sample excludes certain surgical services common in the senior population such as orthopedics and urology.¹² In Phase 1 of the PeCAN program, every patient aged 65 years or older entering the hospital’s PSC receives a brief cognitive screener and frailty assessment.^8,13 The cognitive screener consists of clock drawing to command and copy and a 3-word repeat and recall. When patients make errors on their cognitive screeners, staff refer patients to PeCAN for a Phase 2 preoperative brain health exam; this 90-minute visit consists of a clinical interview, brief neuropsychological testing, and feedback session with a board-certified neuropsychologist. The visit assesses risk for postoperative cognitive complications, neurodegenerative risk factors, and level of independent functioning. Clinical feedback for the patient and caregivers includes anxiety-reduction techniques, strategies to maintain brain health around the time of surgery, and a discussion of cognitive strengths and weaknesses as they pertain to daily functioning.¹⁴ Recommendations to the surgical care team are based on peer-reviewed research regarding strategies to address and mitigate perioperative delirium risk factors in the geriatric population; these include use of intraoperative EEG monitoring, opioid-sparing pain regimens, and considerations for how patients with specific neurocognitive disorders (e.g. Parkinson’s disease) respond differently to anesthetics.^6,7,15–17 Recommendations are made available to the surgeon and anesthesiologist in the electronic medical record system.

Based on recently published data from the PeCAN program, approximately 70 % of patients who are referred for Phase 2 brain health exams exhibit cognitive impairment during their assessment.¹² Phase 3 is a postoperative telephone assessment of cognitive concerns for patients previously evaluated at PeCAN. This telephone assessment is performed by a PeCAN psychometrist about 3–6 weeks post-surgery. For patients who experienced postoperative delirium or cognitive changes, PeCAN will offer a Phase 4 visit with a cognitive and behavioral neurologist. The physician reassesses the patient’s cognitive status for comparison with the preoperative baseline, conducts a neurological examination, orders necessary neuroimaging and bloodwork, and provides clinical recommendations. Recently, healthcare initiatives are emphasizing the importance of patient satisfaction with their practices.¹⁸ Establishing preoperative brain health programs in hospitals may contribute to improved patient satisfaction and perceived quality of hospital care. In perioperative medicine, continuity and quality of care from procedure scheduling to surgical recovery are of utmost concern to reduce complications, costs, and duration of hospital stays.¹⁹ Assessing perceived benefit of the perioperative program to patients is an important part of patient-centered care.^19,20 As older adults undergo nearly 50 % of all surgeries and often have more complex medical profiles requiring multiple specialties and visits,^1,21 there is increased need for quality improvement and patient satisfaction initiatives in geriatric healthcare.²²

1.3. Purpose

The purpose of this study is to assess the value of preoperative brain health exams for older adults and explore areas for patient care improvement based on feedback. Herein, we hypothesized older adults would report satisfaction with preoperative brain health exams provided by the PeCAN program and that the visit would contribute to patients’ confidence in the surgical team’s planning. We examined 1) the degree of satisfaction with a preoperative brain health visit at the PeCAN clinic among older adults via mail-in and electronic survey methods, and 2) themes within patient comments regarding their experience with the PeCAN clinic.

2. Methods

The present study is a retrospective investigation registered through the UF Health Quality Improvement Project Registry (#2178) and approved by the Institutional Review Board (IRB202301442). The authors followed the revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) in the creation of this report.²³ The patients included in this study were 65 years of age and older, seen at the PeCAN clinic preoperatively and completed satisfaction surveys between October 1, 2022 and March 31, 2024 (n = 369). Brain health exams occurred anywhere from one day to several weeks prior to patients’ surgeries depending on clinic availability and when patients were referred for a brain health exam, determined by the timing of their PSC visit. Approximately 50 % of patients were seen via telehealth. Although demographic data was not collected for this specific cohort, based on previous demographic data, PeCAN patients typically have the following characteristics: an estimated mean (SD) age of 73.5 (6.2) years old, 13.8 (2.9) years of formal education and 31 % meet criteria for frailty.^8,12

2.1. Measures

2.1.1. PeCAN mail-in survey

The PeCAN patient satisfaction survey is a postcard with prepaid postage mailed to patients within a week after their brain health exam (Fig. 1). It should be noted that at the time these surveys were created and sent, brain health exams were called “brain wellness exams;” the name was recently changed based on patient stakeholder feedback. Patients were asked to grade their overall satisfaction, scheduling experience, assessment experience, and clinician recommendations on an A-to-F scale. There is also a yes/no question: “Did our consideration of brain wellness improve your confidence in the surgery team and their planning of your care?” There is also a space for optional comments. The survey postcard is mailed with a handwritten notecard thanking the patient for visiting the clinic and wishing them a swift recovery. The PeCAN notecard reminds patients of their visit and helps individualize their care.

Fig. 1.

PeCAN specific satisfaction mail-in postcard.

The PeCAN survey was designed based on the specific demographics of patients seen by PeCAN. It uses a simple grading system and is easy to read, considering that a large proportion of patients visiting PeCAN have an 8th-grade reading level or below^8,12 The mail-in method was chosen based on patient stakeholder feedback informing us they prefer paper over electronic administration. This preference aligns with research showing older adults are less technologically proficient than younger adults and respond to paper surveys at higher rates than electronic surveys.^24,25

2.1.2. Press Ganey electronic survey

The University of Florida Department of Clinical and Health Psychology routinely distributes an electronic patient experience survey via a third-party vendor, Press Ganey^™. This survey was sent to all patients with a valid cell phone number and email address who were seen at Psychology Specialties clinics within UF, including the PeCAN clinic. The first wave of surveys was sent via text message within a week of the visit; the second and third waves were sent via email, giving patients multiple opportunities to respond. The survey consists of general statements about the respondent’s recent behavioral healthcare visit which the respondent is asked to rate on a five-point scale, from 1 being “very poor” to 5 being “very good.” There are five categories of statements, with a total of 19 statements to rate: Access (2); Treatment Area (3); Therapist (7); Your Care (4); Overall Assessment (3). An optional comment text box follows each statement category.

2.2. Data collection

Patients who completed a preoperative brain health exam at the PeCAN clinic were provided two types of anonymous feedback surveys: a PeCAN-specific mail-in satisfaction survey (n = 276) administered between February 24, 2023 and March 7, 2024 and a Press Ganey electronic satisfaction survey (n = 369) administered between October 1, 2022 and March 31, 2024.

2.3. Quantitative analysis

The Press Ganey survey included quarterly reports of mean ratings of each survey statement within the following categories only: “Therapist”, “Your Care”, and “Overall Assessment.” Ratings of 1 to 5 were converted to percentages for purposes of calculating a useful mean score (where 1 = 0 %, 2 = 25 %, 3 = 50 %, 4 = 75 %, 5 = 100 %).

The PeCAN mail-in survey data included A-F ratings for four items (Overall Care, Scheduling Experience, Assessment Experience, and Clinician Feedback Recommendations) and responses to a yes/no question (“Did our consideration of brain wellness improve your confidence in the surgery team and their planning of your care?”). These responses were calculated as percentages for each category for quantitative analysis.

2.4. Qualitative analysis

Optional comments were included in a subset of both the PeCAN mail-in survey and the Press Ganey electronic survey. The mail-in survey included a space for optional comments; in the Press Ganey electronic surveys, each respondent could include up to five comments, each within a specific survey category (Access, Treatment Area, Therapist, Your Care, and Overall Assessment). Comments were analyzed qualitatively to identify common themes within each survey type. Three raters (J.B., Y.J., E.P.), blinded to the grades of the respondents who wrote the comments, grouped comments by thematic category. JB first created a list of thematic categories (some comments fit into multiple categories) based on content, type of criticism or compliment and who it was directed to (PeCAN staff, surgeon, nurses, etc.). Some categories differed for each survey type due to the nature of the surveys. To reduce bias, Y.J. and E.P. independently categorized the comments as well. The three raters conferred to finalize the thematic categories. Raters made conflicting categorizations approximately 15 % of the time but reached a consensus on all comments. A subset of Press Ganey comments were excluded from analysis because the raters determined they could not be interpreted without bias due to their ambiguity (3 %, 5/174). Comments that simply reported no comments or concerns (8 %, 14/174) were also excluded from analysis; this only occurred in the Press Ganey comment set.

3. Results

3.1. Patient satisfaction ratings

The PeCAN mail-in survey was completed by 117/276 (42 %) respondents between February 24, 2023 and March 7, 2024; the Press Ganey electronic survey was completed by 137/369 (37 %) respondents between October 1, 2022 and March 31, 2024.

3.1.1. PeCAN mail-in survey

Based on the PeCAN mail-in survey responses, 95 % of patients were satisfied with their overall care (84 % A, 11 % B), 93 % with scheduling (85 % A, 9 % B), 95 % with the assessment experience (84 % A, 11 % B), and 90 % with clinician feedback recommendations (79 % A, 11 % B; Fig. 2). Additionally, 88 % of respondents reported preoperative consideration of “brain wellness” improved their confidence in their surgical team and the planning of their care.

Fig. 2.

PeCAN specific satisfaction “grades” from mail-in postcard responses.

3.1.2. Press Ganey electronic survey

Based on quarterly reports, mean survey responses within categories “Therapist”, “Your Care”, and “Overall Assessment” ranged from 90 % to 100 %, indicating average “Good” (4/5, 75 % score) to “Very Good” (5/5, 100 % score) ratings (Table 1).

Table 1.

Calculated mean scores for Press Ganey survey questions by time period^*.

	Oct 2022 - Mar 2023	Apr 2023 - Jun 2023	Jul 2023 - Sep 2023	Oct 2023 - Dec 2023	Jan 2024 - Mar 2024
Total Patients Seen	136	60	22	45	106
Total Respondents	n = 41	n = 23	n = 4	n = 20	n = 49
Question
Overall	96.16	94.49	99.38	93.02	95.48
Primary Therapist Overall	97.44	95.38	100.00	92.92	96.30
Primary Therapist Overall†	97.16	94.99	100.00	92.41	95.85
Trust in skill of therapist	97.37	96.74	100.00	95.00	97.45
Therapist concern for your question	97.37	95.65	100.00	93.42	96.94
Therapist understood you	98.03	96.59	100.00	90.79	94.90
Information re: your treatment	96.53	95.00	100.00	92.65	95.92
Prim Ther helped meet treat goals†	95.31	94.44	100.00	91.07	93.89
Therapist used language understood†	97.3	95.65	100.00	94.44	96.35
Prim Ther incl you goal decisions†	96.09	94.74	100.00	91.18	94.79
Your Care Overall	97.2	95.74	100.00	92.00	95.07
Staff concern for your privacy	97.3	95.00	100.00	94.74	96.28
Staff addressed emotional needs	97.37	95.24	100.00	90.79	94.27
Response to concerns/complaints	96.21	96.25	100.00	93.75	93.62
Staff efforts to include care decis	96.97	97.22	100.00	92.19	95.56
Overall Assessment Overall	95.16	97.35	100.00	94.08	96.01
Staff worked together care for you	97.14	95.24	100.00	94.74	96.35
Overall rating of care	95.71	98.86	100.00	95.83	96.20
Likelihood of recommending	96.43	98.75	100.00	92.11	95.21

^*Compared to other behavioral healthcare centers assessed using electronic surveys in the Press Ganey database (mean n = 37), the PeCAN clinic ranked well above the 50th percentile for most questions (97 %).

^†Question is specific to UF Health Behavioral Health Specialties and is not included in other Press Ganey surveys.

3.2. Comment analyses

Of the 117 respondents to the PeCAN mail-in survey, 46 (39 %) wrote comments. The qualitative analysis revealed seven themes with some overlap for individual comments (Supplemental Table A1). The majority of comments (74 %) expressed appreciation for the PeCAN visit: 33 % (15/46) found the preoperative PeCAN visit to be helpful or valuable to their care, 63 % (29/46) expressed gratitude for or were generally complimentary of the PeCAN program or PeCAN staff, and 7 % (3/46) reported the visit reduced their anxiety or offered them comfort prior to surgery. The remainder of comments fell into the following categories: complimentary of the surgical team (9 %, 4/46), patients critiquing the PeCAN program (13 %, 6/46), critiquing the surgical team (4 %, 2/46), and patients who expressed confusion or did not understand the purpose of their visit (11 %, 5/46).

Over the 18 months of data collected via the Press Ganey survey, PeCAN patients wrote 174 comments. Due to the structure of the survey (each respondent can write up to five comments) and anonymous manner of the data reporting, the number of unique commenters is unclear. Qualitative analysis revealed nine themes with some overlap (Supplemental Table A2). Most respondents were complimentary of the PeCAN clinic and/or staff and reported a good experience (42 %, 73/174). Other respondents reported they found their PeCAN visit informative and or valuable to their care (6 %, 10/174), they appreciated the quality of communication at PeCAN (5 %, 8/174), and they found PeCAN staff to be emotionally supportive (5 %, 9/174). About one-third (34 %, 59/174) of Press Ganey comments stated the survey question was not relevant to their PeCAN visit, usually because their visit was conducted via telehealth and the question asked about the physical environment. Since the Press Ganey survey asked about accessibility, some respondents expressed satisfaction with the scheduling process and accessibility of their visit (7 %, 12/174), and a few expressed difficulties accessing their appointment, such as locating the PeCAN clinic in the hospital (3 %, 5/174). A few patients offered critiques of the PeCAN program or staff, such as dissatisfaction with the long duration of their visit (5 %, 8/174). A few respondents confused their clinical PeCAN visit with participation in a research study (2 %, 3/174).

There were five common thematic categories between the surveys (Fig. 3). A higher percentage of mail-in survey comments were complimentary of the PeCAN program/team (63 % vs. 42 %) and expressed the PeCAN visit was valuable (33 % vs. 6 %). The proportion of comments indicating the PeCAN visit reduced stress before surgery was similar for both surveys (5 % electronic vs. 7 % mail-in). Comments critiquing the PeCAN visit occurred at a higher rate in the mail-in survey (13 %) than electronic survey (5 %), as did comments expressing confusion regarding the PeCAN visit (11 % vs. 2 %).

Fig. 3.

Percentage of response type by survey for common comment categories.

4. Discussion

Both electronic and mail-in survey responses suggest PeCAN Phase 2 preoperative brain health exams are perceived as beneficial to older adults electing surgeries. Quantitative satisfaction ratings were similarly high on both survey types: >90 % of respondents were satisfied with all aspects of their experience with the PeCAN clinic. Qualitative feedback showed PeCAN patients overwhelmingly expressed gratitude for the program and staff and found the preoperative visit helpful and informative (“I had an exceptional visit w/ the surgery team and your help was wonderful! It definitely prepared me for surgery! …”). Respondents specifically expressed their appreciation for the quality of communication at PeCAN. These results support research on patient satisfaction among older adults within perioperative care. Trinh and colleagues found that good provider communication, provider care and concern for patients, and meeting patient expectations were most predictive of high patient satisfaction.¹⁸ Several studies support the association between higher patient satisfaction and better clinical outcomes.^18,26 Reducing patients’ anxiety and psychological distress regarding uncertainties surrounding surgery contributed to PeCAN patient satisfaction (“Anxiety-reducing visit. Took away my worries.”). Preoperative stress reduction can reduce postoperative pain and inflammation, thus improving outcomes.²⁷

Another benefit of the PeCAN visit was improvement of patients’ confidence in their surgical care teams. Most patients endorsed increased confidence in their surgical team following their brain health exam. Qualitative feedback from patients revealed complimentary attitudes about the surgical team, as well as suggestions for improvements. Perceived acceptability of and trust in healthcare providers are determining factors in older adults seeking medical care.²⁸ Research indicates ageism is a healthcare concern among providers and patients, and lack of age-related education is most highly associated with ageism.²⁹ In our rapidly aging country, building healthcare programs that advocate for older patients’ needs and value their feedback is important to providing patient-centered care and empowering patients, thus combating ageism in healthcare.

Response rates to the surveys were similar, however, it is unclear if any of the same patients responded to both surveys. A higher proportion of patient comments expressing direct compliments and critiques of the PeCAN visit were provided on the mail-in survey as opposed to the electronic survey. These findings may reflect a higher degree of perceived personalization associated with the mail-in surveys. The electronic survey response may have skewed towards patients with telehealth capabilities, considering that 34 % of the electronic survey comments indicated their PeCAN visit was on telehealth. An estimated 15 % of PeCAN patients are assessed in-person or sometimes over the telephone because they lack computer-based capabilities. Social factors, including low income, social isolation, low education, and rural residency, create unique barriers to internet access for home-bound older adults.³⁰ Many of the surgical patients at UF Health are from deprived areas, per social deprivation indices.^12,31 As technology advances, valuable feedback from the ageing population is at risk of being lost. Using survey methods appropriate for the target population is one way the PeCAN program offers patient-centered care.

4.1. Limitations

Some patients expressed confusion about the purpose of their PeCAN visit. Notably, a few respondents indicated the evaluation was for research (“It was a pleasure to help with this research!”). Confusion may be due to comprehension issues related to cognitive impairment or low health literacy. A limitation to serving a clinical population with a high prevalence of cognitive impairment is increased potential for misunderstanding, particularly regarding abstract concepts such as neurocognitive risk factors for postoperative complications. Nonetheless, this feedback is valuable and will inform future efforts to improve communication on clinical care relevance. One potential strategy is to ask patients to summarize what was accomplished during the visit, thereby re-assessing their level of understanding.

The anonymous nature of both surveys made it impossible to statistically compare patient characteristics for those responding through mail-in vs electronic surveys. We are unable to state if the same patients responded to both surveys or when surveys were completed and returned relative to the surgical procedure. Minimally, we deduce that patients with internet issues who were unable to attend their brain health visit virtually could only have responded to the mail-in survey. Future mail-in surveys could request simple patient demographics and visit type.

To better account for reading level in the population we serve, we plan to revise the yes/no question (“Did our consideration of brain wellness improve your confidence in the surgery team and their planning of your care?”), which currently scores at a 10th-grade Flesch-Kincaid grade level.³² We plan to alter the statement (i.e. “We told your surgeon about your brain health. Did this make you feel better about surgery?”) to one which scores closer to a 4th-grade level.

5. Conclusions

The high satisfaction feedback from patients, combined with other validation studies, show that the PeCAN program adds value to patient-centered geriatric preoperative care. Patients endorsed improved confidence in their surgical team, high satisfaction with and appreciation for PeCAN Phase 2 brain health exams and reported the visit helped them prepare for surgery. This information, combined with critiques from patients, can be used to continue improving care practices and rationalize the establishment of similar programs in additional hospitals.

6. Implications

Determining satisfaction with brain health exams among older adults may encourage patients to pursue future perioperative cognitive evaluations, thus mitigating poor clinical outcomes. Future research should examine relationships between patient satisfaction and postoperative outcomes as well as how patient satisfaction varies with demographics and surgery types. Further validation of the PeCAN program should examine clinical implementation of risk-reducing recommendations and associated postoperative outcomes.

Supplementary Material

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.pcorm.2025.100507.