Patient Satisfication vs Cost


As a foot and ankle surgeon i have routinely discussing patients bunion and treatment options. With the invention of Dr Google patients are coming in asking for a specific surgery and implants which studies has shown will not improve patient satisfaction (1).  So what does? What makes a good surgical outcome? Physician are aggressively target by orthopedic implant companies to try there product and are promised successful outcomes. But it is not well known to the public and talked about is the potential bios in the industry. These financial ties between companies and authors can take many forms: consulting or personal fees, advisory positions, research laboratory space and supplies, financial interest in the company sponsoring the research, or equity interest in the study product. These factors have the potential to effect the choice of implant and clinical outcomes. 


These concerns have been studied in spinal surgery research, for example, it has been shown that statistically significant associations exist between the source of funding, study outcome, and level of evidence and that the majority of published reports represented a low level of clinical evidence and described favorable outcomes (2). These same biases were found in research on the use of acellular dermal matrix in abdominal surgery; an investigation revealed that studies authored by groups disclosing an industry conflict were significantly associated with reporting lower rates of postoperative complications, and, consequently, more positive research results overall (3). Surprisingly, last year in Toronto, Canada at the America Orthopedic Foot and Ankle Society 2016 annual meeting  a well respected and one of my personal favorites in the Foot and Ankle World Dr Roger Mann discussed this concern. It was a short discussion but when Dr Mann publishes literature article or discusses his career people listen. His concern is when doctors are being paid tens of thousands of dollar from companies how can they not be bios? He urged the orthopedic community to stop the financial incentives in there practice. 


With the ever changing health care industry medicare, insurance companies and hospitals have recognized this concern. Not many people are aware medicare as of 2013 sunshine act that allows the public open payments from companies ( https://openpaymentsdata.cms.gov ). This however indicates all type of payments including a cup of coffee to a educational cadaver workshop.  Further, most hospitals have banned on - staff or privileged physician owned orthopedic implant companies to service there patients. One of the biggest changes physicians are now having to juggle is specific patient requests verses what hospitals will allow in the OR. It is still surprising to me how a typical screw for an osteotomy can range from $32 to $600. Therefore most hospitals are now only allowing 1-2 vendors for implants which have substantially reduced the cost of care. However, this is not always the case.  A post op patient of mine was following up for a typical bunion repair and brought in there EOB from the hospital with an implant cost of $700 for a screw that i no was under $50. The patient asked me of the screw was gold plated...i would ask the same question. Therefore does one assume high cost is related to better patient satisfaction?


One article (4) that is pertinent in my profession and what i discuss with all patient prior to bunion or all other foot and ankle surgeries is related to patient expectations. One of my mentors in training Dr Scott Nemerson from SoCal Kaiser Permenante always taught me you can train a monkey to do surgery but you can't teach dedication and personality. Doctors are now so overwhelmed with EMR, patient surveys, bylaws and policies that time is limited to doing the things we love; helping patients return to an active, pain free lifestyle.

A high percentage (25–33%) of patients remain dissatisfied even with improvement in appearance and pain reduction, suggesting that patients have different expectations from surgeons (1). In my experience patients are often dissatisfied with the surgical results because of a lack of understanding about their expectations. Patients whose expectations are more fulfilled report significantly higher satisfaction. Patients should feel comfortable with there surgeon and ask all questions that they have before the surgery date. 

In Conclusion, high cost care is not co-related with higher patient satisfaction. A $32 screw will usually do the same as a $600 screw; however, patient should focus not on adverting of a specific types of surgery or implant but learn more about their surgeon. Feel comfortable, ask about conflicts of interest, laugh, open up and always discuss your expectations as unbiased research indicates you will be satisfied.

 

Darryl J Martins DPM, FACFAS

1. CC Tai et al. Patient expectations for hallux valgus surgery. Journal of Orthopaedic Surgery 2008;16(1):91-5.


2. Amiri AR, Kanesalingam K, Cro S, Casey AT. Does source of funding and conflict of interest influence the outcome and quality of spinal research? Spine J 14:308–314, 2014.


3. DeGeorge BR Jr, Holland MC, Drake DB. The impact of conflict of interest in abdominal wall reconstruction with acellular dermal matrix. Ann Plast Surg 74:242–247, 2015.



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