E. J. Mets, M. R. Mercier, A. S. Hilibrand, M. C. Scott, A. G. Varthi, J. N. Grauer, Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA.
M. C. Scott, Meharry Medical College, School of Medicine, Nashville, TN, USA.
Clin Orthop Relat Res. 2020 Mar;478(3):643-652. doi: 10.1097/CORR.0000000000000892.
Since 2013, the Centers for Medicare & Medicaid Services has tied a portion of hospitals' annual reimbursement to patients' responses to the Hospital Consumer Assessment and Healthcare Providers and Systems (HCAHPS) survey, which is given to a random sample of inpatients after discharge. The most general question in the HCAHPS survey asks patients to rate their overall hospital experience on a scale of 0 to 10, with a score of 9 or 10 considered high, or "top-box." Previous work has suggested that HCAHPS responses, which are meant to be an objective measure of the quality of care delivered, may vary based on numerous patient factors. However, few studies to date have identified factors associated with HCAHPS scores among patients undergoing spine surgery, and those that have are largely restricted to surgery of the lumbar spine. Consequently, patient and perioperative factors associated with HCAHPS scores among patients receiving surgery across the spine have not been well elucidated.
QUESTIONS/PURPOSES: Among patients undergoing spine surgery, we asked if a "top-box" rating on the overall hospital experience question on the HCAHPS survey was associated with (1) patient-related factors present before admission; (2) surgical variables related to the procedure; and/or (3) 30-day perioperative outcomes.
Among 5517 patients undergoing spine surgery at a single academic institution from 2013 to 2017 and who were sent an HCAHPS survey, 27% (1480) returned the survey and answered the question related to overall hospital experience. A retrospective, comparative analysis was performed comparing patients who rated their overall hospital experience as "top-box" with those who did not. Patient demographics, comorbidities, surgical variables, and perioperative outcomes were compared between the groups. A multivariate logistic regression analysis was performed to determine patient demographics, comorbidities, and surgical variables associated with a top-box hospital rating. Additional multivariate logistic regression analyses controlling for these variables were performed to determine the association of any adverse event, major adverse events (such as myocardial infarction, pulmonary embolism), and minor adverse events (such as urinary tract infection, pneumonia); reoperation; readmission; and prolonged hospitalization with a top-box hospital rating.
After controlling for potential confounding variables (including patient demographics), comorbidities that differed in incidence between patients who rated the hospital top-box and those who did not, and variables related to surgery, the patient factors associated with a top-box hospital rating were older age (compared with age ≤ 40 years; odds ratio 2.2, [95% confidence interval 1.4 to 3.4]; p = 0.001 for 41 to 60 years; OR 2.5 [95% CI 1.6 to 3.9]; p < 0.001 for 61 to 80 years; OR 2.1 [95% CI 1.1 to 4.1]; p = 0.036 for > 80 years), and being a man (OR 1.3 [95% CI 1.0 to 1.7]; p = 0.028). Further, a non-top-box hospital rating was associated with American Society of Anesthesiologists Class II (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.024), Class III (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.020), or Class IV (OR 0.2 [95% CI 0.1 to 0.5]; p = 0.003). The only surgical factor positively associated with a top-box hospital rating was cervical surgery (compared with lumbar surgery; OR 1.4 [95% CI 1.1 to 1.9]; p = 0.016), while nonelective surgery (OR 0.5 [95% CI 0.3 to 0.8]; p = 0.004) was associated with a non-top-box hospital rating. Controlling for the same set of variables, a non-top-box rating was associated with the occurrence of any adverse event (OR 0.5 [95% CI 0.3 to 0.7]; p < 0.001), readmission (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.023), and prolonged hospital stay (OR, 0.6 [95% CI 0.4 to 0.8]; p = 0.004).
Identifying patient factors present before surgery that are independently associated with HCAHPS scores underscores the survey's limited utility in accurately measuring the quality of care delivered to patients undergoing spine surgery. HCAHPS responses in the spine surgery population should be interpreted with caution and should consider the factors identified here. Given differing findings in the literature regarding the effect of adverse events on HCAHPS scores, future work should aim to further characterize this relationship.
Level III, therapeutic study.
自 2013 年以来，医疗保险和医疗补助服务中心已将医院年度报销的一部分与患者对医院消费者评估和医疗保健提供者及系统（HCAHPS）调查的反应挂钩，该调查在出院后对随机抽取的住院患者进行。HCAHPS 调查中最常见的问题是要求患者对其整体医院体验在 0 到 10 的范围内进行评分，得分 9 或 10 被认为是高的，或“满分”。之前的研究表明，HCAHPS 反应，旨在作为提供的护理质量的客观衡量标准，可能因众多患者因素而异。然而，迄今为止，很少有研究确定了接受脊柱手术的患者的 HCAHPS 评分与患者因素之间的关系，而且这些研究主要限于腰椎手术。因此，接受脊柱手术的患者的 HCAHPS 评分与患者和围手术期因素之间的关系尚未得到很好的阐明。
问题/目的：在接受脊柱手术的患者中，我们询问在 HCAHPS 调查中对整体医院体验问题的“满分”评分是否与（1）患者入院前存在的因素；（2）与手术相关的手术变量；和/或（3）30 天围手术期结果相关。
在 2013 年至 2017 年期间在一家学术机构接受脊柱手术的 5517 名患者中，有 27%（1480 名）患者返回了调查并回答了与整体医院体验相关的问题。进行了回顾性、比较性分析，比较了对整体医院体验评为“满分”的患者和未评为“满分”的患者。比较了两组患者的人口统计学、合并症、手术变量和围手术期结局。进行了多变量逻辑回归分析，以确定与满分医院评分相关的患者人口统计学、合并症和手术变量。进行了额外的多变量逻辑回归分析，控制了这些变量，以确定任何不良事件、主要不良事件（如心肌梗死、肺栓塞）和次要不良事件（如尿路感染、肺炎）；再次手术；再次入院；以及与满分医院评分相关的住院时间延长。
在控制了潜在的混杂变量（包括患者的人口统计学）、患者评分差异的合并症以及与手术相关的变量后，与医院评分满分的患者相比，与医院评分满分的患者相比，年龄较大（与年龄≤40 岁相比；优势比 2.2[95%置信区间 1.4 至 3.4]；p = 0.001 为 41 至 60 岁；OR 2.5[95%CI 1.6 至 3.9]；p<0.001 为 61 至 80 岁；OR 2.1[95%CI 1.1 至 4.1]；p = 0.036 岁> 80 岁），并且是男性（优势比 1.3[95%置信区间 1.0 至 1.7]；p = 0.028）。此外，非满分医院评分与美国麻醉师协会（ASA）分级 II（OR 0.5[95%CI 0.3 至 0.9]；p = 0.024）、III（OR 0.5[95%CI 0.3 至 0.9]；p = 0.020）或 IV（OR 0.2[95%CI 0.1 至 0.5]；p = 0.003）相关。唯一与满分医院评分相关的手术因素是颈椎手术（与腰椎手术相比；OR 1.4[95%CI 1.1 至 1.9]；p = 0.016），而非择期手术（OR 0.5[95%CI 0.3 至 0.8]；p = 0.004）与非满分医院评分相关。在控制了相同的一组变量后，非满分评分与任何不良事件的发生相关（OR 0.5[95%CI 0.3 至 0.7]；p<0.001）、再次入院（OR 0.5[95%CI 0.3 至 0.9]；p = 0.023）和住院时间延长（OR，0.6[95%CI 0.4 至 0.8]；p = 0.004）。
确定手术前与 HCAHPS 评分相关的患者因素强调了该调查在准确衡量接受脊柱手术的患者所接受的护理质量方面的有限效用。应谨慎解释脊柱手术人群中的 HCAHPS 反应，并应考虑到此处确定的因素。鉴于文献中关于不良事件对 HCAHPS 评分的影响存在不同的发现，未来的工作应旨在进一步描述这种关系。
III 级，治疗性研究。
