Patient Satisfaction in the Preoperative Period: Preparing for Hand Surgery

Abstract

Background: The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Methods: Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Results: Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, P = 0.005) and 5 or more total encounters (80%, P = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon (P = 0.267) or medical office encounters (P = 0.087), or a patient’s perceived health status (P = 0.14). Conclusions: Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.

Introduction

With health care incentives and reimbursement transitioning from volume- to value-based, the business and patient-centered care models of practice are becoming increasingly intertwined. Patient experience is now widely accepted as a health care measure and component of health care quality, often reported as patient satisfaction scores.⁸ With the introduction of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) has brought a focus on the need to deliver care that provides a quality patient experience as a part of overall health care delivery. CMS now publicly reports patient satisfaction using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.⁸ Furthermore, CMS adjusts reimbursements based on various quality measures including clinical processes of care, outcomes, efficiency, and patient experience.² These policies directly relate patient satisfaction to health care quality.⁵

While outpatient patient satisfaction metrics are not currently required, they are increasingly used by health systems to evaluate surgeon performance and to determine compensation.¹ Such publically available statistics may impact patient referrals or patient’s own practice selection for elective procedures. In addition, satisfied patients are more likely to be compliant and keep office appointments, while less likely to pursue litigation or file complaints.³

Several studies have investigated individual encounter characteristics including time spent in the waiting room and with the surgeon, surgeon empathy, and communication barriers such as language^6,7,9; however, we are unaware of any prior studies evaluating the potential cumulative impact preoperative encounters may have on satisfaction rates, as multiple of various types are commonly required. Given the growing emphasis on patient satisfaction as a component of patient-centered care and its role in patient referral, surgeon evaluation, and reimbursement, we sought to evaluate the potential impact of the number and type of preoperative encounters, including both telephone and office visits, on satisfaction rates prior to elective outpatient hand surgery.

Materials and Methods

Following institutional review board approval, 200 consecutive patients presenting for elective hand surgery were prospectively evaluated and asked to complete a questionnaire investigating satisfaction with the preoperative process. All patients had presented to a single academic practice, including 5 participating hand surgeons. The practice included both an urban and suburban clinical office location (2 offices total) and was primarily outpatient surgical center based for procedures (including 1 urban and suburban location), with a single hospital setting available for scheduling at surgeon preference. All patients 18 years or older were considered eligible for inclusion, regardless of procedure type. Only patients with inability or refusal to complete the supplied questionnaire or those submitting an incomplete questionnaire were excluded. Patients were consecutively enrolled at the 2 surgical centers and single hospital site from April 1, 2017, to August 1, 2017, and informed consent was obtained from all individual participants included in the study.

Upon presentation to the preoperative check-in at their surgical site, patients were provided informed consent and a printed questionnaire. The questionnaire was derived from the Clinician and Group-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Adult Visit Survey, a standardized survey instrument developed by the Agency for Healthcare Research and Quality to assess patients’ experience and perception of care in ambulatory office settings, including hand surgery. Demographic data including age, sex, occupation (student, working, retired, disabled/unemployed), as well as procedure type and location (surgical center or hospital) were recorded. Next, the number of telephone encounters with office staff, surgeon and medical clearance provider office encounters, and the total number of overall encounters from the time of initial presentation to the time of surgery were recorded. As a measure of patient satisfaction, each encounter type was evaluated on a 4-category Likert scale, with responses of 1 (extremely satisfied), 2 (somewhat satisfied), 3 (averagely satisfied), or 4 (somewhat or very dissatisfied). Patients were considered “satisfied” if responding 1 or 2 (extremely or somewhat satisfied). Patients also evaluated their own perceived health status on a 4-category Likert scale, with responses of 1 (very healthy), 2 (few, well controlled medical problems), 3 (moderate number of controlled medical problems), or 4 (mix of controlled and uncontrolled medical problems). Statistical analysis of continuous data was presented in terms of means and standard deviations, while categorical data was reported with frequencies and percentages. Fisher exact tests were used to evaluate the association between overall satisfaction and the number of encounters of each type, including the total number of encounters. In addition, satisfaction with surgeon and medical provider office encounters were evaluated individually via the same method.

A priori power analyses were conducted to estimate the required sample size. Given the nature of this research and the attendant uncertainties, a range of sample size estimates were generated reflecting these uncertainties. Based on these a priori analyses, a sample size of 200 respondents was estimated to be sufficient to achieve greater than 90% power at α = 0.05 (adjusted to consider 3 multiple comparisons) to detect an effect size (Cohen’s W) of 0.33 based on 2 groups measured on the 5-unit Likert scale. However, when the study was executed, we saw much higher satisfaction ratings and much smaller group differences than we anticipated. Given these very high satisfaction ratings, data in the 2 lowest rating categories were very sparse. Accordingly, the 2 lowest categories were aggregated into a single category, and the data were analyzed based on a 4-level ratings. As a result, the study as executed is underpowered for some tests or comparisons to achieve statistical significance given the very small observed differences between the various groups. Whereas the observation of both high satisfactions and small differences between groups is informative and encouraging, future studies in this domain should be sized to consider these high satisfactions and the resulting small differences between groups.

Results

Among 200 patients presenting for elective hand surgery, 197 completed the entire questionnaire and were included. The mean patient age was 57.9 ± 16.6 years and 56.3% of the population was female (Table 1). 86.3% of cases occurred at outpatient surgical centers, with the most common surgical procedures being carpal tunnel and trigger finger release (47.2% and 16.8%, respectively). Patient’s most commonly categorized their occupation as actively working (50.2%) or retired (33%), with 11.2% of our patient population unemployed or disabled (Table 1).

Table 1.

Demographics.

Variable	N	Frequency/%
Age	197	57.9 (mean)
Sex
Female	111	56.3%
Male	86	43.7%
Occupation status
Student	11	5.6%
Working	99	50.2%
Retired	65	33.0%
Disabled	11	5.6%
Unemployed	11	5.6%
Total	197	100%
Surgery location
Hospital	27	13.7%
Outpatient surgical center	170	86.3%
Total	197	100%
Surgery type
Carpal tunnel release	93	47.2%
Distal radius ORIF	15	7.6%
Trigger finger release	33	16.8%
Other	56	28.4%
Total	197	100%

Note. ORIF = open reduction and internal fixation.

Overall satisfaction with the preoperative scheduling and medical clearance process was 92.9% (extremely or somewhat satisfied), with only 3% of patients dissatisfied (Table 2). There was a statistically significant association between patient satisfaction and the number of telephone and total encounters (combined telephone, surgeon, and medical office). Patient satisfaction fell below 90% after 4 or more telephone calls (66.6% satisfaction, P = 0.005) and 5 or more total encounters (80% satisfaction, P = 0.008) (Table 3). The number of “extremely satisfied” patients progressively declined with each telephone encounter, with the most significant decline following the fourth encounter (33.3% satisfaction, P = 0.005). When considered individually, there was no statistically significant association between patient satisfaction and the number of surgeon (P = 0.267) or medical clearance provider office encounters, although data suggested the number of “extremely satisfied” patients steadily declined with each subsequent medical clearance encounter (P = 0.087) (Table 4). A patient’s perception of their health status also was not significantly associated with their overall satisfaction rate with the preoperative scheduling process (P = 0.74) (Table 5).

Table 2.

Overall Patient Satisfaction (Combined Telephone, Surgeon, Medical Encounters).

Overall satisfaction	N (% of total)
Extremely satisfied	161 (81.7)
Somewhat satisfied	22 (11.2)
Averagely satisfied	8 (4.1)
Somewhat or very dissatisfied	6 (3.0)
Total	197 (100)

Table 3.

Patient Satisfaction Rates for Telephone and Total Encounters.

	Extremely satisfied	Somewhat satisfied	Averagely satisfied	Somewhat or very dissatisfied	Total	P value
Number of telephone encounters
0	51 (87.9%)	4 (6.9%)	2 (3.4%)	1 (1.7%)	58 (100.0%)
1	69 (83.1%)	10 (12.0%)	3 (3.6%)	1 (1.2%)	83 (100.0%)
2	29 (82.9%)	2 (5.7%)	3 (8.6%)	1 (2.9%)	35 (100.0%)
3	9 (75.0%)	3 (25.0%)	0 (0.0%)	0 (0.0%)	12 (100.0%)
4+	3 (33.3%)	3 (33.3%)	0 (0.0%)	3 (33.3%)	9 (100.0%)
Total	161 (81.7%)	22 (11.2%)	8 (4.1%)	6 (3.0%)	197 (100.0%)
						0.0050
Number of total encounters
1	25 (92.6%)	1 (3.7%)	1 (3.7%)	0 (0.0%)	27 (100.0%)
2	40 (85.1%)	4 (8.5%)	2 (4.3%)	1 (2.1%)	47 (100.0%)
3	54 (85.7%)	7 (11.1%)	1 (1.6%)	1 (1.6%)	63 (100.0%)
4	22 (88.0%)	2 (8.0%)	1 (4.0%)	0 (0.0%)	25 (100.0%)
5	13 (65.0%)	3 (15.0%)	3 (15.0%)	1 (5.0%)	20 (100.0%)
6+	7 (46.7%)	5 (33.3%)	0 (0.0%)	3 (20.0%)	15 (100.0%)
Total	161 (81.7%)	22 (11.2%)	8 (4.1%)	6 (3.0%)	197 (100.0%)
						0.0082

Table 4.

Patient Satisfaction Rates for Surgeon and Medical Office Encounters.

	Extremely satisfied	Somewhat satisfied	Averagely satisfied	Somewhat or very dissatisfied	Total	P value
Number of surgeon office encounters
0	12 (80.0%)	2 (13.3%)	0 (0.0%)	1 (6.7%)	15 (100.0%)
1	139 (81.8%)	20 (11.8%)	6 (3.5%)	5 (2.9%)	170 (100.0%)
2+	10 (83.3%)	0 (0.0%)	2 (16.7%)	0 (0.0%)	12 (100.0%)
Total	161 (81.7%)	22 (11.2%)	8 (4.1%)	6 (3.0%)	197 (100.0%)
						0.2674
Number of medical clearance encounters
0	51 (91.1%)	2 (3.6%)	3 (5.4%)	0 (0.0%)	56 (100.0%)
1	90 (81.1%)	14 (12.6%)	3 (2.7%)	4 (3.6%)	111 (100.0%)
2	14 (73.7%)	3 (15.8%)	1 (5.3%)	1 (5.3%)	19 (100.0%)
3+	7 (63.6%)	3 (27.3%)	1 (9.1%)	0 (0.0%)	11 (100.0%)
Total	162 (82.2%)	22 (11.2%)	8 (4.1%)	5 (2.5%)	197 (100.0%)
						0.0866

Table 5.

Patient’s Health Description and Satisfaction Rates.

	Extremely satisfied	Somewhat satisfied	Averagely satisfied	Somewhat or very dissatisfied	Total	P value
Own health description
Very healthy, no medical problems	52 (81.3%)	6 (9.4%)	4 (6.3%)	2 (3.1%)	64 (100.0%)
A few, well-controlled medical problems	76 (86.3%)	7 (8.0%)	2 (2.3%)	3 (3.4%)	88 (100.0%)
Moderate number of controlled medical problems	25 (78.1%)	5 (15.6%)	1 (3.1%)	1 (3.1%)	32 (100.0%)
Mix of controlled and uncontrolled medical problems	10 (76.9%)	3 (23.1%)	0 (0.0%)	0 (0.0%)	13 (100.0%)
Total	163 (82.7%)	21 (10.7%)	7 (3.6%)	6 (3.0%)	197 (100.0%)
						0.7372

Discussion

Patient experience is now widely accepted as a health care measure and component of health care quality, which is used by both health care systems and the public for evaluating physician performance. CMS, as well as private health care systems, may adjust reimbursement based on various quality measures that include not only outcomes and efficiency, but also patient experience.² Furthermore, publically available statistics may impact patient referrals or a patient’s practice selection for elective procedures.⁴ Despite growing emphasis on patient satisfaction as a component of patient-centered care, satisfaction literature is limited and typically derived from postoperative surveys. We are unaware of any prior studies evaluating the potential impact the number and type of preoperative physician encounters may have on patient satisfaction, yet this may generate several points of potential inconvenience or frustration.

Patient satisfaction rates vary among medical specialties and are affected by several individual visit characteristics. In our study, overall satisfaction with the preoperative process was 92.9%, which is consistent with other office based satisfaction investigations.^6,7,9 Specific to hand surgery, several authors have investigated different characteristics of individual office visits that may affect patient satisfaction. Teunis et al reported time spent with the hand surgeon was not associated with patient satisfaction, while longer waiting room times correlated with decreased satisfaction.⁹ Menendez et al investigated the role of language as a potential barrier to a satisfactory experience, reporting only a 71% satisfaction rate of Spanish-speaking patients, versus 91% of English speakers, following an office visit.⁷ None of these studies included analysis of multiple office visits or the potential cumulative effect of these characteristics on satisfaction rates. Within our data set, there was a statistically significant association between patient satisfaction and both the number of telephone and total encounters (combined telephone, surgeon and medical office), each suggestive of a negative correlation between satisfaction and an increasing number of encounters. Patient satisfaction remained very high, above 90%, until 4 or more telephone calls (66.6% satisfaction, P = 0.005) and 5 or more total encounters (80% satisfaction, P = 0.008) (Table 3). The number of “extremely satisfied” patients progressively declined subsequently with each telephone encounter, again highlighting the cumulative effect an increasing number of encounters may have on satisfaction and the importance of preoperative efficiency when scheduling and medically clearing patients for outpatient, elective procedures. Importantly, this includes not only office visits but also telephone contact with office staff.

When considered individually, there was no statistically significant association between patient satisfaction and the number of surgeon (P = 0.267) or medical clearance provider office encounters (P = 0.087). These results suggest the type of encounter may be less significant than the number of encounters when considering satisfaction. However, the type of encounter should not be entirely ignored. Although lacking statistical significance in our patient series, the number of “extremely satisfied” patients steadily declined with each subsequent medical clearance encounter, with the largest decrease occurring between 0 and 1 encounter (91% vs 81% extremely satisfied patients, respectively). This downward trend of “extremely satisfied” patients as the number of medical clearance encounters increased may approach significance in a larger series. This is an important consideration for physicians who prefer to request medical clearance visits for even “minor” outpatient procedures, as these data support the conclusion that while patient’s do not view this request as an major inconvenience, minimizing the number of encounters supports high satisfaction. A patient’s perception of their health status was not significantly associated with their overall satisfaction (P = 0.74) (Table 5). Satisfaction rates were similarly high among all groups in the preoperative period, regardless of presence or lack of medical comorbidities.

There are several limitations of our study. First, our questionnaire was modeled from items of the HCAHPS survey relevant to our study without separate validation of our scoring characteristics. This may limit the reliability and generalizability of our satisfaction measure. However, this is not inconsistent with previous investigations,⁹ as validation of most satisfaction instruments is limited. Second, the previously validated items included⁸ cannot be considered a full representation of the likely multifactorial contributors to preoperative patient satisfaction. This further supports the need for development of a more thoroughly validated and widely applicable satisfaction instrument that would benefit future research on this topic. Additional questions not included here that may be appropriate for further study include specific determinants for those patients expressing dissatisfaction. Satisfaction rates within our population were high (183 patients or 92.9% extremely/somewhat satisfied), and as a result, some of the conclusions of this study are based on a small number of patients (14 patients or 7.1% average/somewhat satisfied or dissatisfied). A multicenter approach in the future may be of benefit for increasing the number and diversity of patients as well as clinical and surgical locations to provide more robust and generalizable data.

In conclusion, greater than 3 telephone or 4 total personal encounters in the preoperative period significantly decreases patient satisfaction prior to elective hand surgery. The lack of an association between patient satisfaction and the number of surgeon or medical office encounters when considered individually further supports the concept that the number of encounters is more significant than encounter type. Communication experts emphasize quality over quantity of communication,¹⁰ and prior investigations suggest patient-rated physician empathy rather than visit duration strongly correlates with the degree of overall satisfaction in an outpatient hand surgery setting.⁶ Effective communication with patients has been shown to instill trust, strengthen patient-provider relationships, and increase patient compliance and outpatient follow-up rates, while also decreasing complaints or litigation.³ Efforts to make hand surgery office, telephone, and medical clearance provider encounters more patient-centered, with a focus on improving dialogue quality, may decrease unnecessary visits or patient contact that may negatively affect a patient’s experience.