Patient satisfaction is a poor surrogate for quality of care in brain surgery

Patient satisfaction is a very poor proxy for quality of care comparisons in elective cranial neurosurgery. Because deaths are rare events in elective cranial neurosurgery, reporting of surgeon or even department-specific mortality figures cannot differentiate a high or low level of the quality of care.

The current focus on patient safety in health care has led to public quality-of-care comparisons between health care facilities and even between individual health care professionals. In the United States, a new reimbursement method based on patient satisfaction ratings was announced by the Centers for Medicare and Medicaid Services in 2011.1 In New South Wales, Australia, patient satisfaction rates are publicly available online for open comparisons between treatment centers.2 In the United Kingdom, the National Health Service (NHS) mandates the National Neurosurgical Audit Programme (NNAP) by the Society of British Neurological Surgeons to report the 30-day risk-adjusted mortality rates for individual neurosurgeons in England.3

The Hospital District of Helsinki and Uusimaa, Helsinki, Finland, is one of the largest public, tertiary, and non-profit hospital organizations in the world with 22,000 employees and more than 500,000 treated patients each year. The first prospective observational patient-centered study on quality of care and patient satisfaction in elective cranial neurosurgery was conducted between 7 December, 2011, and 31 December, 2012, at the Department of Neurosurgery, Helsinki University Hospital, a part of the Hospital District of Helsinki and Uusimaa. Recently, the results of this study were published in the Neurosurgery.

In this prospective observational cohort study on 418 unselected adult patients undergoing elective craniotomy, recorded outcomes included anesthesiologist-reported as well as patient-reported postoperative complications, and overall patient satisfaction. Patients reported their subjective postoperative complications on a patient questionnaire at discharge. At 30 postoperative days, the overall patient satisfaction was surveyed with a structured telephone interview. Two-thirds of the patients had intracranial tumors and one-third underwent major cerebrovascular surgery. A majority (62%) were female and 30% were aged 65 years or more.

Major postoperative complications after elective craniotomy were rare. The most common major complication was transient or permanent hemiparesis in 41 (10%) patients. Altogether 17 patients (4%) underwent repeat craniotomy or postoperative endovascular intervention. The rates of other major complications were low: pneumonia 3%, silent stroke 1%, acute myocardial infarction 1%, pulmonary embolism 1%, and deep vein thrombosis 1%. With patient-reported postoperative complications such as transient subjective visual disturbances and difficulty of swallowing included, almost one-half (46%) suffered postoperative complications. Postoperative mortality in the cohort was low: the in-hospital mortality rate was 1% and 30-day mortality rate 2%

A vast majority, 94% of patients, rated their overall satisfaction as good or excellent. Even nine of ten patients with major postoperative complications gave good or excellent overall satisfaction ratings. Poor patient satisfaction ratings were most often reported by patients with minor complications such as urinary tract infections; many of these patients experienced multiple minor postoperative complications.

The results of this pioneer study show that the rate of major complications after elective craniotomy at the Department of Neurosurgery, Helsinki University Hospital, is exceptionally low, and overall patient satisfaction is high, even if postoperative major complications occur. In this one-year cohort at one of the largest tertiary neurosurgical centers in the world, only 10 patients died within 30 days after surgery indicating that mortality alone is too crude as an outcome measure for modern cranial neurosurgery, and an unreliable tool for comparisons between treatment centers and individual surgeons.

"Overall patient satisfaction is a very poor proxy for quality of care in brain surgery, because satisfaction ratings fail to reflect the occurrence of postoperative complications," says Dr Elina Reponen, and continues: "Even in large neurosurgical centers, the postoperative mortality rates are too low to enable any meaningful comparisons between treatment centers or individual neurosurgeons."

"USA and Great Britain together with many other countries may need to define more reliable measures for reporting quality of care in brain surgery," Dr Miikka Korja concludes.