Letters
tients’ care experiences without also assessing indicators of clinical quality. For example, the Centers for Medicare & Medicaid Services Hospital Compare website publicly reports hospitals’ performance on multiple measures: patient survey results, process measures indicating timeliness and effectiveness of care, and clinical outcome measures, including readmissions, complications, and mortality, several of which are surgery-specific. In the Centers for Medicare & Medicaid Services’ fiscal year 2014 Hospital Inpatient Value-Based Purchasing Program, newly-added outcome measures will account for 25%, the patient experience survey for 30%, and clinical process measures for 45% of hospitals’ Total Performance Scores. Patient centeredness is one of the cardinal features of highquality care.5 Since the 1990 article cited by Lyu et al,1 much progress has been made in developing standardized surveys of patient experience that directly evaluate patient centeredness, a unique and intrinsically important aspect of care quality that is not otherwise measured. For patient-centered care to be valued alongside other dimensions of care quality, measures of patient experience must be included among the broader set of measures used to assess performance and promote quality improvement. Rebecca Anhang Price, PhD Marc N. Elliott, PhD Alan M. Zaslavsky, PhD Author Affiliations: RAND Corporation, Arlington, Virginia (Anhang Price); RAND Corporation, Santa Monica, California (Elliott); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Zaslavsky). Corresponding Author: Rebecca Anhang Price, PhD, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202 ([email protected]). Conflict of Interest Disclosures: Drs Anhang Price, Elliott, and Zaslavsky have been funded by the Centers for Medicare & Medicaid Services, and Drs Elliott and Zaslavsky have also been funded by the Agency for Healthcare Research and Quality as investigators in the development and implementation of Consumer Assessments of Healthcare Providers and Systems surveys. Additional Contributions: We thank Paul Cleary, PhD, Ron Hays, PhD, and William Lehrman, PhD, for their comments on a draft of this letter. 1. Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367. 2. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-1040. 3. Lehrman WG, Elliott MN, Goldstein E, Beckett MK, Klein DJ, Giordano LA. Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care. Med Care Res Rev. 2010;67(1):38-55. 4. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353(3):265-274. 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001.
In Reply A bedside central line insertion is much different from a mitral valve replacement or robotic prostatectomy. Patients are awake during bedside central line placements; thus, they are able to provide their feedback on perceptions of cleanliness and nursing care. This explains the association between Healthcare Providers and Systems Survey patient satisfaction scores and the incidence of central line– associated bloodstream infections in the intensive care 986
unit.1 However, under general anesthesia, it is unlikely that a patient can evaluate quality of care. Although we agree with the conclusions of Saman and Kavanagh and Price et al, there are unique aspects to surgical care that deserve to be distinguished from other aspects. Patients can experience poor medical care and still be extremely satisfied. For example, a patient could be satisfied with an open aortic aneurysm repair even though the patient could have been an ideal candidate for an aortic stent graft. Patients’ perceptions of the quality of their surgery can outweigh several important issues: Was the right operation performed? Was surgery even necessary? Was it performed with technical excellence? Relying heavily on satisfaction in the absence of meaningful outcome measures may be appropriate for some areas of medicine, but, in surgery, patient satisfaction likely represents one of many domains of quality. In a bold effort to bring attention to the aforementioned issues, the Institute of Medicine reported that up to 30% of what we do in health care may be unnecessary.2 Also, the Choosing Wisely campaign lists tests and procedures that are commonly performed when they are not indicated.3 These are the leading issues of surgical quality. In fact, many of the Choosing Wisely items are surgical, including preoperative tests and studies. Although satisfaction is easily measurable, it is probably limited in what it tells us about what happens in the operating room. In our article, we affirmed the importance of patient satisfaction by stating that “[w]e applaud the introduction of patient satisfaction as a metric of health care.”4(p365) Furthermore, we maintained that patient satisfaction speaks to high-quality services and that “[t]hese important services may be surrogates of a well-coordinated and patientcentered level of service.”4(p365) However, patient satisfaction may be skewed by confounding variables. For example, in our hospital’s large chronic pancreatitis center, we treat a high volume of patients with drug addictions and other chronic problems. A uniform 30% payment adjustment based on satisfaction does not account for differences in patient populations. Furthermore, unadjusted patient satisfaction scores could create perverse incentives for hospitals to avoid difficult patient populations. Also, Price et al argue that patient satisfaction is one of many different quality metrics in surgery; however, the metrics that they describe are only collected for 6 operations out of the hundreds performed regularly in US hospitals. Although the Centers for Medicare & Medicaid Services do list surgery-specific clinical outcome measures, including mortality, readmission, and complications, on their website, the existing data are premature and extremely limited. Although our study was limited, we observed the need for meaningful surgical metrics, such as those collected by the American College of Surgeons National Surgical Quality Improvement Program, to accompany patient satisfaction transparency. Heather Lyu Michol Cooper, MD, PhD Julie A. Freischlag, MD Martin A. Makary, MD, MPH
JAMA Surgery October 2013 Volume 148, Number 10
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/08/2015
jamasurgery.com
Letters
Author Affiliations: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (Lyu, Cooper, Freischlag, Makary). Corresponding Author: Martin A. Makary, MD, MPH, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Halsted 610, Baltimore, MD 21287 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS One. 2013;8(4):e61097. 2. Committee on the Learning Health Care System in American. Best Care at Lower Cost: The path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press; 2012.
4. Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367.
CORRECTION Incorrect Information in Text: In the Original Investigation entitled “Systemic Review and Meta-analysis of Randomized Clinical Trials Comparing Primary vs Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions” published in the August 2013 issue of JAMA Surgery (2013;148[8]:779-786. doi: 10.1001/jamasurg.2013.2336), incorrect information appeared. In the first sentence of the Primary Outcome subsection of the Results section, the P value for chance of surgical site infection should be .02. In Table 1, Table 2, and Figure 2, the source “Chang et al22” should be “Chiang et al15.” This article was corrected online.
3. Choosing Wisely: an initiative of the ABIM Foundation. Lists: Specialty society lists of five things physicians and patients should question (for physicians). ABIM Foundation website. http://www.choosingwisely.org/doctor -patient-lists/. Updated 2013. Accessed May 20, 2013.
jamasurgery.com
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/08/2015
JAMA Surgery October 2013 Volume 148, Number 10
987
tients’ care experiences without also assessing indicators of clinical quality. For example, the Centers for Medicare & Medicaid Services Hospital Compare website publicly reports hospitals’ performance on multiple measures: patient survey results, process measures indicating timeliness and effectiveness of care, and clinical outcome measures, including readmissions, complications, and mortality, several of which are surgery-specific. In the Centers for Medicare & Medicaid Services’ fiscal year 2014 Hospital Inpatient Value-Based Purchasing Program, newly-added outcome measures will account for 25%, the patient experience survey for 30%, and clinical process measures for 45% of hospitals’ Total Performance Scores. Patient centeredness is one of the cardinal features of highquality care.5 Since the 1990 article cited by Lyu et al,1 much progress has been made in developing standardized surveys of patient experience that directly evaluate patient centeredness, a unique and intrinsically important aspect of care quality that is not otherwise measured. For patient-centered care to be valued alongside other dimensions of care quality, measures of patient experience must be included among the broader set of measures used to assess performance and promote quality improvement. Rebecca Anhang Price, PhD Marc N. Elliott, PhD Alan M. Zaslavsky, PhD Author Affiliations: RAND Corporation, Arlington, Virginia (Anhang Price); RAND Corporation, Santa Monica, California (Elliott); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Zaslavsky). Corresponding Author: Rebecca Anhang Price, PhD, RAND Corporation, 1200 S Hayes St, Arlington, VA 22202 ([email protected]). Conflict of Interest Disclosures: Drs Anhang Price, Elliott, and Zaslavsky have been funded by the Centers for Medicare & Medicaid Services, and Drs Elliott and Zaslavsky have also been funded by the Agency for Healthcare Research and Quality as investigators in the development and implementation of Consumer Assessments of Healthcare Providers and Systems surveys. Additional Contributions: We thank Paul Cleary, PhD, Ron Hays, PhD, and William Lehrman, PhD, for their comments on a draft of this letter. 1. Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367. 2. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-1040. 3. Lehrman WG, Elliott MN, Goldstein E, Beckett MK, Klein DJ, Giordano LA. Characteristics of hospitals demonstrating superior performance in patient experience and clinical process measures of care. Med Care Res Rev. 2010;67(1):38-55. 4. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353(3):265-274. 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001.
In Reply A bedside central line insertion is much different from a mitral valve replacement or robotic prostatectomy. Patients are awake during bedside central line placements; thus, they are able to provide their feedback on perceptions of cleanliness and nursing care. This explains the association between Healthcare Providers and Systems Survey patient satisfaction scores and the incidence of central line– associated bloodstream infections in the intensive care 986
unit.1 However, under general anesthesia, it is unlikely that a patient can evaluate quality of care. Although we agree with the conclusions of Saman and Kavanagh and Price et al, there are unique aspects to surgical care that deserve to be distinguished from other aspects. Patients can experience poor medical care and still be extremely satisfied. For example, a patient could be satisfied with an open aortic aneurysm repair even though the patient could have been an ideal candidate for an aortic stent graft. Patients’ perceptions of the quality of their surgery can outweigh several important issues: Was the right operation performed? Was surgery even necessary? Was it performed with technical excellence? Relying heavily on satisfaction in the absence of meaningful outcome measures may be appropriate for some areas of medicine, but, in surgery, patient satisfaction likely represents one of many domains of quality. In a bold effort to bring attention to the aforementioned issues, the Institute of Medicine reported that up to 30% of what we do in health care may be unnecessary.2 Also, the Choosing Wisely campaign lists tests and procedures that are commonly performed when they are not indicated.3 These are the leading issues of surgical quality. In fact, many of the Choosing Wisely items are surgical, including preoperative tests and studies. Although satisfaction is easily measurable, it is probably limited in what it tells us about what happens in the operating room. In our article, we affirmed the importance of patient satisfaction by stating that “[w]e applaud the introduction of patient satisfaction as a metric of health care.”4(p365) Furthermore, we maintained that patient satisfaction speaks to high-quality services and that “[t]hese important services may be surrogates of a well-coordinated and patientcentered level of service.”4(p365) However, patient satisfaction may be skewed by confounding variables. For example, in our hospital’s large chronic pancreatitis center, we treat a high volume of patients with drug addictions and other chronic problems. A uniform 30% payment adjustment based on satisfaction does not account for differences in patient populations. Furthermore, unadjusted patient satisfaction scores could create perverse incentives for hospitals to avoid difficult patient populations. Also, Price et al argue that patient satisfaction is one of many different quality metrics in surgery; however, the metrics that they describe are only collected for 6 operations out of the hundreds performed regularly in US hospitals. Although the Centers for Medicare & Medicaid Services do list surgery-specific clinical outcome measures, including mortality, readmission, and complications, on their website, the existing data are premature and extremely limited. Although our study was limited, we observed the need for meaningful surgical metrics, such as those collected by the American College of Surgeons National Surgical Quality Improvement Program, to accompany patient satisfaction transparency. Heather Lyu Michol Cooper, MD, PhD Julie A. Freischlag, MD Martin A. Makary, MD, MPH
JAMA Surgery October 2013 Volume 148, Number 10
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/08/2015
jamasurgery.com
Letters
Author Affiliations: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (Lyu, Cooper, Freischlag, Makary). Corresponding Author: Martin A. Makary, MD, MPH, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Halsted 610, Baltimore, MD 21287 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS One. 2013;8(4):e61097. 2. Committee on the Learning Health Care System in American. Best Care at Lower Cost: The path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press; 2012.
4. Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367.
CORRECTION Incorrect Information in Text: In the Original Investigation entitled “Systemic Review and Meta-analysis of Randomized Clinical Trials Comparing Primary vs Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions” published in the August 2013 issue of JAMA Surgery (2013;148[8]:779-786. doi: 10.1001/jamasurg.2013.2336), incorrect information appeared. In the first sentence of the Primary Outcome subsection of the Results section, the P value for chance of surgical site infection should be .02. In Table 1, Table 2, and Figure 2, the source “Chang et al22” should be “Chiang et al15.” This article was corrected online.
3. Choosing Wisely: an initiative of the ABIM Foundation. Lists: Specialty society lists of five things physicians and patients should question (for physicians). ABIM Foundation website. http://www.choosingwisely.org/doctor -patient-lists/. Updated 2013. Accessed May 20, 2013.
jamasurgery.com
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/08/2015
JAMA Surgery October 2013 Volume 148, Number 10
987
