Association between patient characteristics and dissatisfaction after cranial neurosurgery: A prospective observational study

INTRODUCTION

Patient satisfaction is an individual’s assessment and emotional response to health-care experience and is an indicator of the quality of healthcare.^[1,2] It largely depends on the alignment of the patient’s perceived expectations and actual health outcomes.^[1] The patient satisfaction is not only a desired result of healthcare but also a means to improve treatment outcomes.^[3] Dissatisfied patients often tend to have a poor health-related quality of life.^[4] The patient dissatisfaction may be due to clinical or non-clinical factors or both.^[5] The patient dissatisfaction varies depending on the type of surgery, time of evaluation, and the assessment methods used.

While there are many studies evaluating perioperative patient satisfaction after non-cranial surgeries, there is paucity of literature on patient satisfaction after cranial neurosurgery.^[6,7] Hence, it is important to assess this patient reported outcome in this specific surgical population, especially in the developing countries where no such data is available. This knowledge will provide insights about the magnitude of dissatisfaction and potential factors contributing to it and if the patient dissatisfaction affects post-operative outcomes.

The primary objective of the present study was to determine the incidence of patient dissatisfaction with regard to perioperative care after cranial neurosurgery. The secondary objective was to identify patient characteristics that contribute to dissatisfaction after surgery. We also aimed to assess the impact of post-operative dissatisfaction on clinical outcomes of ambulation and duration of hospital stay after the surgery.

MATERIALS AND METHODS

RESULTS

A total of 1491 patients undergoing neurosurgery were screened for eligibility for recruitment and 496 patients were included into the study. However, 106 patients were excluded from the analysis for reasons mentioned in the flow diagram [Figure 1] and data from 390 patients were analyzed.

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Figure 1:

Flow diagram showing patient flow into the study.

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The overall incidence of patient dissatisfaction assessed 24 h after cranial neurosurgery was 20.5% (80/390). The results of the univariate analysis on comparing the potential risk factors for post-operative satisfaction and dissatisfaction after cranial neurosurgery are presented in [Table 1]. Among the potential risk factors assessed, literacy, economic status, pre-operative pain, and anxiety were found to be associated with post-operative patient dissatisfaction. A binary logistic regression model was used to identify independent predictors of patient dissatisfaction [Table 2]. Illiteracy, higher economic status, and absence of pre-operative anxiety were found to be predictors of post-operative dissatisfaction. The patient dissatisfaction did not impact the time for ambulation or duration of hospital stay after the surgery [Table 3].

DISCUSSION

Studies on patient satisfaction after cranial neurosurgery are scarce. A previous study which evaluated patient satisfaction 30 days after cranial neurosurgery observed a patient dissatisfaction rate of 6% among the 418 patients studied.^[6] The patient satisfaction was dependent on functional status, infections, overall health status, and severity of symptoms.^[6] We observed a higher (20%) dissatisfaction rate when assessment was done during the early post-operative period. It is likely that dissatisfaction decreases over time as patients may not recollect their exact experience about the perioperative period after a significant delay or their views about certain aspects of perioperative care that led to the reporting of early dissatisfaction might not seem important at a later time point. In patients undergoing microvascular decompression (MVD) and partial sensory rhizotomy (PSR) for trigeminal neuralgia, dissatisfaction was noted in 4% and 20% of patients after MVD and PSR, respectively.^[7] Our findings in overall cranial surgery population are similar to that observed after PSR but different after MVD. This suggests that within the cranial neurosurgery cohort itself, the patient dissatisfaction varies depending on the type of surgery the patient undergoes. The predictors of patient satisfaction in patients undergoing spine surgeries were patient and healthcare worker relationship, age, health status, length of hospital stay, pain, complications, readmission, and psychological factors such as depression and distress.^[5] Among the patients surveyed in neurosurgery outpatient clinics, older age, cranial diagnosis, surgeon’s recommendation for surgery, and access to government health insurance were associated with better patient satisfaction.^[9] A shorter symptom duration and immediate pain improvement after surgery were associated with better patient satisfaction after cervical spine surgery.^[10] Among the several patient characteristics that we explored as risk factors, we observed only illiteracy, higher economic status, and absence of pre-operative anxiety to be predictors of patient dissatisfaction after cranial neurosurgery.

Literate patients tend to be more satisfied with health-care services.^[11] Conversely, patients with lower levels of education tend to be more dissatisfied with pre-operative care.^[12] This was noted in our study too where illiteracy predicted patient dissatisfaction after cranial neurosurgery. It is important for health-care facilities to arrange for easy-to-comprehend materials and information to accommodate for illiterate patients when educating them about surgery, anesthesia, and perioperative course.

We observed that patients who paid from their pockets for the surgery and hospital services were more dissatisfied than patients below the poverty line. Poor patients whose health-care expenses are taken care by public funding are more receptive to the quality of perioperative care available for free to them. In contrast, patients who pay out of their pockets have higher expectations which often do not match the actual deliverables in a government hospital and, hence, tend to be more dissatisfied. Similar observations were reported in a non-surgical population from Iran, where patients from higher economic status reported more dissatisfaction.^[13] However, the opposite is also seen where patients with low-income reporting more dissatisfaction and vice versa.^[14] This is mainly due to poor access and quality of healthcare that they receive and may not be applicable to hospitalized patients undergoing surgery.

Higher pre-operative anxiety has been associated with more dissatisfaction in the previous studies.^[15] In contrast, dissatisfaction was not noted in patients with pre-operative anxiety in the present study. Three main categories of pre-operative anxiety exist: Concern about the unknown, fear of getting ill, and concern for one’s life.^[16] However, if the anxiety provoking stimulus is not followed with the feared consequence, the anxiety related to the stimulus reduces.^[17] Moreover, pre-operative anxiety is significantly higher than the post-operative anxiety.^[18] Therefore, after the surgery, in the absence of the feared consequence and uncertainty, perhaps our patients were less anxious than anticipated and consequently, more satisfied.

No other factor that we assessed in our study was associated with dissatisfaction after cranial neurosurgery. A previous study in patients undergoing total knee arthroplasty noted that post-operative pain but not pre-operative pain was associated with dissatisfaction after surgery.^[19] We did not find either pre-operative or post-operative pain to be predictive of patient dissatisfaction. In an earlier study, despite 76% of the 191 patients reporting moderate-to-severe pain after surgery, satisfaction rate was high at 81%.^[20] Similar findings were seen in another study where despite 86% patients experiencing post-operative pain, 90% reported satisfaction with the care they received.^[21] Thus, the relationship between pain and satisfaction appears be complex. The patient satisfaction is likely to be higher if response of the health-care providers to their pain is humane, timely, and appropriate, even if they perceive higher pre- and post-operative pain.

Pre-operative depression was not associated with postoperative depression in our study. The relationship between depression and satisfaction is inconsistent with some studies observing dissatisfaction among the patients with pre-operative depression,^[22] while others finding no association between the two,^[11] similar to our findings.

Several factors that were not associated with patient dissatisfaction in our study were also not predictive of dissatisfaction in earlier studies. Older age and comorbidities were not associated with patient dissatisfaction in the present study, similar to previous studies.^[6] Gender and occupation were not associated with patient satisfaction in our study as well as some previous studies.^[23] We did not observe craniotomy site to be predictive of patient satisfaction which was similar to the results of a previous study.^[6] The patients’ perception about surgery was not associated with their post-operative satisfaction in our study. Although this was not exactly explored in earlier studies, not meeting pre-operative expectations of surgical outcomes did not result in dissatisfaction after spine surgeries.^[24] The previous studies have found no relationship between patient dissatisfaction and length of hospital stay,^[12] corroborating our results.

Strengths and limitations

This is probably the first study from a developing world to assess dissatisfaction, an important patient reported outcome, after cranial neurosurgery. We explored the relationship between various patient characteristics and dissatisfaction, and also the impact of dissatisfaction on ambulation time and duration of hospital stay after surgery. However, there are certain important limitations. First, the patient satisfaction was assessed at only one time point. Perhaps the findings would be different if satisfaction was to be assessed at later time points. Second, we explored only the relationship between patient characteristics and dissatisfaction about perioperative care. The patient satisfaction can be impacted by other domains such as hospital environment (lighting, ventilation, noise, cleanliness, etc.), availability of family support, cost of surgery and hospitalization, waiting time for surgery and cancellations, prognosis of neurosurgical illness, and humanistic factors such as healthcare workers’ attitudes toward patients and their perioperative issues. These factors were not assessed in this study. Finally, as patient characteristics can vary between developing and developed world and between various types of surgeries, our findings regarding dissatisfaction after cranial neurosurgery from an Indian hospital may not be generalizable to populations which are dissimilar to that of our study.

CONCLUSION

Every one in five patients in our study reported dissatisfaction after cranial neurosurgery. Illiteracy, higher economic status, and absence of pre-operative anxiety were predictive of patient dissatisfaction. However, dissatisfaction was not associated with longer time to ambulation or hospital discharge. Improving literacy (including health literacy) as a broad public health measure and providing value for money for paying patients as a specific intervention may help reduce dissatisfaction among patients undergoing cranial neurosurgery in a health-care setup similar to ours.