preoperative patient-reported health status measures, and
completed postoperative HCAHPS surveys. From the preoperative questionnaires, moderate to severe depression was
identified with the Patient Health Questionnaire 9 (PHQ- 9).
From the postoperative HCAHPS surveys, 21 items were assessed for percentage of “top-box” responses (the best option
in a non-numbered scale, or a 9 or 10 out of 10 on a numbered
scale). Comparisons were then made between HCAHPS
responses of those who had been found to be depressed and
those found to be non-depressed patients using multivariate
regression analysis to control for patient factors more prevalent among the depressed population.
In total, the study identified 160 patients as non-depressed
and 57 patients as depressed (about a quarter of their population having moderate to severe depression preoperatively).
The depressed group were more likely to be younger, women,
patients on disability and current tobacco users. Additionally,
depressed patients were found to have higher preoperative
pain and disability (determined by Pain Disability Questionnaire [PDQ] scores) and lower preoperative quality of life
(determined by EuroQol five dimensions [EQ-5D] scores).
The patients with preoperative depression were significantly less likely to rate their hospital experience as “top-box.”
Specifically, the depressed population gave significantly lower
ratings to six survey items when compared with the non-depressed population. These included:
“Doctors always treated you with courtesy and respect.”
“Doctor always listened carefully to you.”
“Nurses always treated you with courtesy and respect.”
“After you pressed the call button, you always got help
as soon as you wanted it.”
“Hospital staff talked with you about whether you would
have the help you needed when you left the hospital.”
Due to differences in preoperative characteristics between
the depressed and non-depressed patients, the study included
a multivariate logistic regression analysis. This comprehensive
analysis controlled for covariates such as quality of life, sex,
age, tobacco use and pain and disability scores.
After correcting for these factors, Levin et al found de-
pression to be an independent predictor of lower HCAHPS
scores. In particular, those who tested positive for depression
rated interpersonal relationships between nurses and doctors
significantly lower, felt they did not receive help fast enough,
and noted lower rates of discussion about postdischarge care.
As a result, the authors suggested that depression should be
considered as an adjustment factor for HCAHPS responses.
The authors note limitations of this study to include its
relatively small sample size, and the fact that it took place
at a single tertiary care center (The Cleveland Clinic). They
posit that their patient mix may be different than that found in
other health care systems. Additionally, the authors question
whether the lower scores from the depressed population were
a result of heightened sensitivity in those patients or whether
they were actually treated differently. It is certainly possible
that doctors and nurses might have treated these depressed
patients differently, since depressed patients may have a flat
affect or be more combative and distrustful, making interac-
tions with them more difficult for health care providers.
This study is timely, as increasing emphasis is being placed
on HCAHPS scores. Under the Center for Medicare and
Medicaid Services (CMS) Hospital Value-Based Purchasing
system, HCAHPS scores are tied to hospital reimbursement.
As a result, hospital income is becoming increasingly depen-
dent on these patient satisfaction scores. Consequently, it is
important to explore factors that might influence these results.
The study’s utilization of preoperative health status scores
for the patient population strengthens the findings. It is
certainly notable that a significant percentage of patients
undergoing lumbar fusion surgery in the study population
were moderately or severely depressed. The use of multivari-
ate analysis to account for discrepancies in patient population
characteristics supports the assertion that depression was an
independent predictor of lower HCAHPS scores.
One area that was not discussed but may have affected the
Preoperative depression was an independent predictor of
lower HCAHPS scores in a retrospective cohort of lumbar
Depressed patients rated interpersonal relationships between
nurses and doctors significantly lower.
The importance of depression on HCAHPS responses needs to
be acknowledged and potentially adjusted for.
Strengths of Study
The study used preoperative health status scores to identify
depression among the patient population.
A multivariate analysis adjusting for patient characteristics
associated with depression confirmed that depression was an
independent predictor of lower HCAHPS scores.
Limitations of Study
It is unclear whether lower scores were a result of heightened
sensitivity in depressed patients or different treatment by
health care providers.
The study has a potential for selection bias based on who
completed the HCAHPS survey.
The study only reviewed the “top box” responses instead of
the full spectrum of responses.