PREOPERATIVE FACCTORS ASSOCIATED WITH PRESS GANEY PATIENT SATISFACTION SCORES AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Patient satisfaction is increasingly used as a metric to evaluate the quality of healthcare services and to determine hospital and physician compensation. The aim of this study was to identify preoperative factors associated with Press Ganey Ambulatory Surgery (PGAS) satisfaction scores, and to evaluate the effect of each PGAS domain score on the total PGAS score variability in patients undergoing anterior cruciate ligament reconstruction (ACLR). A review of a Press Ganey (PG) database at a single center was performed for patients undergoing ACLR between 2015 and 2019. Ninety-nine patients completed the PGAS survey and 54 also completed preoperative demographic and patient-reported outcome measures (PROMs) for an orthopaedic registry. PGAS scores were calculated and bivariate analysis was performed. Multivariable linear regression determined the effect of each of the six PGAS domains on the total PGAS score variability. In the total cohort of 99 patients, no factors were significantly associated with the total PGAS score or any domain scores. For the 54 patients who also participated in the orthopaedic registry, none of the preoperative PROMs were significantly correlated with total PGAS score. However, having a college degree (89 vs. 95 or 97 points; p = 0.02) and continuous femoral nerve catheter (92 vs. 100 points; p = 0.04) was associated with lower personal issue domain scores, while patients with a greater number of prior surgeries had worse registration domain scores (ρ = -0.27; p = 0.049). For the entire cohort, the registration and facility domains contributed the most variability to the total PGAS score, while the physician domain contributed the least. Few preoperative factors are associated with PGAS scores, and total PGAS scores do not significantly correlate with baseline PROMs. Surgeons may have limited ability to improve their PGAS scores given most of the variability in total scores stems from systemic aspects of the patient experience.

Discussion

Considering the emphasis healthcare has placed on patient satisfaction to determine physician reimbursement, understanding the factors affecting patients' perception of the operative experience is critical. There is a lack of prior research evaluating the factors associated with PG scores in sports medicine patients, particularly those undergoing ACLR. The current study identified several patient and surgical factors that were associated with worse PGAS domain scores in patients undergoing ACLR, but none of the factors were significantly associated with the total PGAS score. Additionally, the registration and facility domains were associated with the greatest variability in the total PGAS score, while the physician domain was the least influential. The results of this study do not provide reliable targets for hospital systems to improve total PGAS survey scores. The lack of correlation with validated baseline PROMs should caution the interpretation of PGAS scores and their use for future reimbursement.

Literature describing patient satisfaction following ACLR is limited, and no prior studies have determined the factors associated with PG survey scores in this patient population. Kocher et al previously determined predictors of patient satisfaction at a minimum of 2 years after ACLR, showing improved satisfaction with better 2-year IKDC scores and less satisfaction in the presence of a lateral meniscus tear. This is consistent with prior research demonstrating the long-term importance of the lateral meniscus. In contrast, the current study did not find an association between meniscus tears and PGAS scores.

Despite a lack of data reporting satisfaction after ACLR, satisfaction rates are generally high. A recent report demonstrated 85.4% of patients are very satisfied following ACLR, and 10.3% of patients are somewhat satisfied. These findings, however, were reported at a minimum of 2 years follow-up, and patients were more likely to be satisfied if they returned to sport. The current study showed similarly high satisfaction scores in the immediate postoperative period with a mean total PGAS score of 92 out of 100 points. Since PG has not released percentiles for PGAS scores after ACLR, the ceiling effects of the survey may render seemingly high scores in a low percentile nationally. Additionally, return to sport, a major contributor to patient satisfaction after ACLR, cannot be assessed within the 6 weeks postoperative timeframe when the PGAS survey is administered. Therefore, the relatively high total PGAS score reported in this study is unlikely to represent long-term patient satisfaction with their surgery, but rather satisfaction with their perioperative experience.

While no prior studies examined the association between PG surveys and PROMs in patients undergoing ACLR, multiple studies with conflicting results exist for other orthopaedic populations. For patients undergoing total hip and knee arthroplasty, Chughtai et al found no significant correlations between PG scores and common PROMs. These studies, however, assessed PROMs 2 years postoperatively, while the current study used baseline PROMs given their proximity to the timing of PGAS survey administration. The current study did not show any significant correlations between total PGAS and baseline PROMIS scores, but did show a significant, weakly positive correlation between PROMIS anxiety scores and the overall assessment domain. These findings conflict with prior research showing higher baseline PROMIS anxiety scores are associated with worse overall assessment PG scores in follow-up hand clinic patients. Inconsistent correlations between PROMs and PG surveys in orthopaedic research show the patient experience may be independent of measurable outcomes.

The results of this study showed correlations between several factors and PGAS domain scores. First, patients with a college degree had worse personal issue scores. By contrast, orthopaedic clinic patients with lower socioeconomic status have been previously shown to have worse PG scores. The findings in the present study may indicate patients with higher socioeconomic status have higher expectations of healthcare systems to properly address issues that arise during encounters. Second, patients who had a continuous femoral nerve catheter had worse personal issue scores, yet prior studies have shown pain control after total knee arthroplasty is associated with better patient satisfaction scores. These conflicting findings may be explained by the logistics of the continuous catheter itself, rather than the efficacy of pain control, as patients with or without a single-shot nerve block did not have significant differences in satisfaction scores. While the continuous femoral catheter is also a postoperative factor, it was included in this study because the catheter is placed preoperatively. Third, an increasing number of prior surgeries was weakly negatively correlated with registration PGAS scores. More surgical experiences likely provide greater context for the registration process, and deviation from patient expectations likely leads to worse scores in this domain. Finally, multiple authors in the outpatient clinic setting have shown that older age is associated with improved PG scores. The current study did not show associations between PGAS scores and older age, which is likely due to the younger cohort inherent to ACLR. Overall, the associations observed in the current study are weak, and the findings are likely not generalizable to other patient populations. It is important to recognize the inconsistent findings in the literature related to patient satisfaction surveys, as they potentially carry financial implications.

Finally, the registration and facility domain scores in the current study were responsible for the greatest variability in the total PGAS score. The physician domain accounted for the least variability in the total PGAS score and had the highest mean score of any domain. This indicates that the surgeons consistently met the expectations of patients during their encounters, and surgeons have little room to improve their PGAS scores. Much of the PGAS score variability remains outside of the control of the surgeon, despite one report that the physician score is the most influential for the total PG score in orthopaedic clinic patients. Such differences may be related to patient expectations in the clinic versus the surgical center, as patients are concerned with wait times and the time spent with the physician in the clinic setting.

There are several limitations to this study. The greatest weakness of the study is the small sample size due to the 11.9% (99/829 ACLRs) response rate to the PGAS survey. The response rate is within the 8.9 to 16.5% range presented for orthopaedic clinic patients.The sample size in the current study is much smaller than prior PG studies, as most studies include heterogenous clinic populations. This study, however, specifically assessed ambulatory surgery encounters, which are less frequent than clinic encounters, in a homogenous population of patients undergoing ACLR over a 5-year period. Importantly, PG claims 30 responses is an adequate sample size to draw meaningful conclusions of a practice, and encounters with this minimum cutoff will be used for national rankings.So, the data in this study represent all the available responses for national rankings over a 5-year period for a single institution. Second, a smaller cohort of patients (n = 54) was enrolled in the orthopaedic registry, limiting the analysis for certain variables. Differences in the subgroups were minimal, as only the number of meniscus tears were different in the registry group. Finally, the results of this study may not be generalizable to other patient populations given the data are from a single academic, urban population.

In summary, this is the first study to evaluate the PGAS survey in patients undergoing ACLR procedures. While no significant correlations were shown between preoperative patient factors and the total PGAS score, there were multiple weak correlations for the registration, personal issue, and overall assessment scores. Except for the type of regional anesthesia, the number of prior surgeries, education level, and baseline anxiety level of patients undergoing ACLR are largely nonmodifiable factors weakly associated with PGAS scores. Given these findings and a lack of consistency in the literature regarding the factors associated with PG scores, we cannot recommend specific modifiable patient targets for surgery centers to improve PGAS scores in patients undergoing ACLR. Given the registration and facility scores contributed the greatest variability to the total PGAS score, improving the patient experience in these areas may have the greatest impact. The surgeon contributed the least to the variability of the total score, and physician domain scores were consistently high, demonstrating that PGAS scores may be out of the control of the surgeon. This has important implications to future reimbursement and PGAS scores should be interpreted with caution. Future studies should determine if PGAS scores are correlated with surgical satisfaction and long-term PROMs in patients undergoing ACLR.

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Published January 3, 2022 in the Journal of Knee Surgery.