• Jay M Levin, Robert D Winkelman, Gabriel A Smith, Joseph E Tanenbaum, Roy Xiao, Thomas E Mroz, and Michael P Steinmetz.
• Cleveland Clinic Center for Spine Health, 9500 Euclid Avenue, S-40 Cleveland, Ohio 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, Ohio 44106, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, S-40 Cleveland, Ohio 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, S-40 Cleveland, Ohio 44195, USA. Electronic address: jml247@case.edu.
• Spine J. 2018 Feb 1; 18 (2): 226-233.

BackgroundHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are used to assess the quality of the patient experience following an inpatient stay. Hospital Consumer Assessment of Healthcare Providers and Systems scores are used to determine reimbursement for hospital systems and incentivize spine surgeons nationwide. There are conflicting data detailing whether early readmission or other postdischarge complications are associated with patient responses on the HCAHPS survey. Currently, the association between postdischarge emergency department (ED) visits and HCAHPS scores following lumbar spine surgery is unknown.PurposeTo determine whether ED visits within 30 days of discharge are associated with HCAHPS scores for patients who underwent lumbar spine surgery.Study DesignRetrospective cohort study.Patient SampleA total of 453 patients who underwent lumbar spine surgery who completed the HCAHPS survey between 2013 and 2015 at a single tertiary care center.Outcome MeasuresThe HCAHPS survey-the Centers for Medicare and Medicaid Services' official measure of patient experience-results for each patient were analyzed as the primary outcome of this study.MethodsAll patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy or scoliosis. Patients who had an ED visit at our institution within 30 days of discharge were included in the ED visit cohort. The primary outcomes of this study include 21 measures of patient experience on the HCAHPS survey. Statistical analysis included Pearson chi-square for categorical variables, Student t test for normally distributed continuous variables, and Mann-Whitney U test for nonparametric variables. Additionally, log-binomial regression models were used to analyze the association between ED visits within 30 days after discharge and odds of top-box HCAHPS scores. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.ResultsAfter adjusting for patient-level covariates using log-binomial regression models, we found postdischarge ED visits were independently associated with lower likelihood of top-box score for several individual questions on HCAHPS. Emergency department visits within 30 days of discharge were negatively associated with perceiving your doctor as "always" treating you with courtesy and respect (risk ratio [RR] 0.26, p<.001), as well as perceiving your doctor as "always" listeningcarefully to you (RR 0.40, p=.003). Also, patients with an ED visit were less likely to feel as if their preferences were taken into account when leaving the hospital (RR 0.61, p=.008), less likely to recommend the hospital to family or friends (RR 0.46, p=.020), and less likely to rate the hospital as a 9 or a 10 out of 10, the top-box score (RR 0.43, p=.005).ConclusionsOur results demonstrate a strong association between postdischarge ED visits and low HCAHPS scores for doctor communication, discharge information, and global measures of hospital satisfaction in a lumbar spine surgery population.Copyright © 2017 Elsevier Inc. All rights reserved.

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