Elsevier

The Spine Journal

Volume 13, Issue 5, May 2013, Pages 501-506
The Spine Journal

Clinical Study
Preoperative Zung depression scale predicts patient satisfaction independent of the extent of improvement after revision lumbar surgery

https://doi.org/10.1016/j.spinee.2013.01.017Get rights and content

Abstract

Background context

Patient satisfaction ratings are increasingly being used in health care as a proxy for quality and are becoming the focal point for several quality improvement initiatives. Affective disorders, such as depression, have been shown to influence patient-reported outcomes and self-interpretation of health status. We hypothesize that patient psychiatric profiles influence reported satisfaction with care, independent of surgical effectiveness.

Purpose

To assess the predictive value of preoperative depression on patient satisfaction after revision surgery for same-level recurrent stenosis.

Patient sample

Fifty-three patients undergoing a revision surgery for symptomatic same-level recurrent stenosis.

Outcome measures

Patient-reported outcome measures were assessed using an outcomes questionnaire that included questions on health state values (EuroQol-5D [EQ-5D]), disability (Oswestry Disability Index [ODI]), pain (visual analog scale [VAS]), depression (Zung self-rating depression scale), and Short Form 12 (SF-12) physical and mental component scores (PCS and MCS). Patient satisfaction was dichotomized as either “YES” or “NO” on whether they were satisfied with their surgical outcome 2 years after the surgery.

Methods

A total of fifty-three patients undergoing revision neural decompression and instrumented fusion for same-level recurrent stenosis-associated back and leg pain were included in this study. Preoperative Zung self-rating depression score (ZDS), education status, comorbidities, and postoperative satisfaction with surgical care and outcome was assessed for all patients. Baseline and 2-year VAS for leg pain (VAS-LP), VAS for low back pain (VAS-BP), ODI, SF-12 PCS and MCS, and health-state utility (EQ-5D) were assessed. Factors associated with patient satisfaction after surgery were assessed via multivariate logistic regression analysis.

Results

Two years after surgery, a significant improvement was reported in all outcome measures: VAS-BP (5±2.94 vs. 9.28±1, p<.001), VAS-LP (3.43±2.95 vs. 9.5±0.93, p<.001), ODI (21.75±12.07 vs. 36.01±6, p<.001), SF-12 PCS (32.30±11.01 vs. 25.13±5.84, p<.001), SF-12 MCS (47.48±10.96 vs. 34.91±12.77, p<.001), EQ-5D (0.60±0.31 vs. 0.18±0.22, p<.001), and ZDS (37.52±11.98 vs. 49.90±10.88, p<.001). Independent of postoperative improvement in pain and disability (surgical effectiveness), increasing preoperative Zung depression score was significantly associated with patient dissatisfaction 2 years after revision lumbar surgery (Odds ratio=0.67 [confidence interval: 0.38, 0.87], p<.001).

Conclusions

Our study suggests that independent of the surgical effectiveness, the extent of preoperative depression influences the reported patient satisfaction after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality should account for the patients' baseline depression as potential confounders.

Introduction

Evidence & Methods

Patient satisfaction metrics are one standard dimension of determining treatment outcomes but have in some studies appeared to track poorly with other outcome measures. In this article, the authors assess whether depression predicts satisfaction regardless of functional outcome as measured on commonly-employed self-report questionnaires.

Depression predicted poorer satisfaction with treatment, but this dissatisfaction appeared independent of the reported functional outcomes following surgery.

The findings are interesting and corroborate some surgeons' experiences. A disconnect between satisfaction and outcomes has been noted in both directions in prior studies. As the authors suggest, patient-reported post hoc satisfaction as a measure of global ‘quality’ should be reconsidered, especially when significant depression is noted prior to surgery. Discussion of psychological factors affecting outcomes in spinal surgery may be an important aspect of informed consent as well.

—The Editors

Patient satisfaction scales are being used with an increasing frequency in health care as a proxy for quality [1], [2], [3], [4], [5]. In fact, patient satisfaction ratings are of an increasing interest to the health maintenance organizations or health insurance companies that wish to negotiate prices when purchasing health care [6], [7], [8]. Accordingly, over the past decade, there has been a growing interest from health care providers for validated patient-reported measures of satisfaction, which may be used as a reliable proxy for quality. The Joint Commission on Accreditation of Health Care Organizations has identified patient satisfaction as an important measure of program quality and suggests that this measure should be included in the accreditation process for health care organizations [9]. Similarly, the US Department of Veterans Affairs also includes patient satisfaction within its strategic plan for patient care. However, the measure “patient satisfaction” will have limited utility if the associated confounding factors are not clearly identified.

Recent studies have demonstrated that patient satisfaction is an important prognostic factor for treatment compliance and maintenance of a continuous “physician-patient” relationship. However, only a few studies have evaluated the extent to which affective disorders, such as depression, influence reported patient satisfaction and self-interpretation of health status, with conflicting results. Linn et al. [10] reported that the psychological status strongly influenced the patient-reported satisfaction ratings. Similarly, Meredith et al. [11] demonstrated an association between patient dissatisfaction and adherence to clinical recommendations in patients with depression. Conversely, Greenley et al. found no association between affective disorders in psychologically distressed patients and patient-reported satisfaction ratings [12]. Hence, the effect of affective disorders on patient satisfaction remains unclear.

Patients requiring revision spinal surgery are a particularly challenging cohort to treat. Revision surgery can be technically challenging, and the patients often present with long durations of symptoms coupled with anxiety regarding previous surgeries, which they perceived to be treatment failures. These patients represent a unique group in which psychological factors, such as depression and somatic perception, may play a particularly important role in their perception of overall satisfaction, despite surgical effectiveness. To date, no studies have investigated confounders of patient-reported satisfaction ratings that influence self-interpretation of health status. We theorize that patient baseline psychiatric profiles may influence reported satisfaction with health care independent of surgical effectiveness.

Given the paucity of data assessing the effect of preoperative depression on reported patient satisfaction, we set out to assess the predictive values of preoperative depression and educational status on the patient satisfaction after revision lumbar surgery for same-level recurrent stenosis.

Section snippets

Patient selection

Fifty-three consecutive patients undergoing revision neural decompression (laminectomy/foraminotomy) and instrumented fusion for recurrent same-level stenosis were included in this study. The primary inclusion criteria of the study were the following: previous lumbar laminectomy; magnetic resonance imaging evidence of same-level stenosis; presence of mechanical back and radicular leg pain; age between 18 and 70 years; and treatment failure of at least 6 months of conservative therapy. The

Results

A total of 53 consecutive patients presenting with symptomatic same-level recurrent stenosis were enrolled in the study. All patients were available for a follow-up at 2 years. Overall, the mean (±SD) age was 56.27±12.48 years (35 women, 18 men), Table 1. All patients presented with leg pain and radiographic evidence of central stenosis with or without the evidence of lateral recess stenosis. Levels L4–L5 (40%) and L5–S1 (37%) were the most frequently involved spinal levels. Eight (15%)

Discussion

In a 2-year longitudinal cohort study, we set out to assess the predictive value of preoperative depression on patient satisfaction after revision lumbar surgery for same-level recurrent stenosis. Independent of surgical effectiveness (improvement in ODI), the presence and magnitude of depression were significantly and independently associated with patient dissatisfaction with overall quality of care. Preoperative Zung depression score considerably influenced reported patient satisfaction and

Conclusions

Our study suggests that independent of surgical effectiveness, the extent of preoperative depression influences the patient-reported satisfaction with surgical outcome after revision lumbar surgery. Quality improvement initiatives using patient satisfaction as a proxy for quality should account for patients' baseline depression as a potential confounder.

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    Author disclosures: OA: Nothing to disclose. SLP: Nothing to disclose. DNS: Nothing to disclose. SKM: Nothing to disclose. AB: Research Support (Staff/Materials): Johnson and Johnson (D, Paid directly to institution/employer). JSC: Nothing to disclose. ALA: Stock ownership: HyperBranch Medical Technology (E); Consulting: Medtronic (C); Trips/Travel: HyperBranch Medical Technology (None); Board of Directors: Neuropoint Alliance (None). MJM: Research Support (Staff/Materials): Globus (E), Depuy (E).

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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