Background
Subjective outcome parameters such as self-assessment of function, quality of life or patient satisfaction have become fundamental tools for outcome assessment of orthopaedic interventions [
1]. Patient satisfaction is a reliable indicator of health care quality, enabling the comparison between different health care providers [
2]. Patient reported outcomes may guide patients to choose their health care provider and could substantially influence competition in health care markets [
3] [
4]. Objective treatment success is essential, but not the only condition, which generates patient satisfaction [
5,
6]. Many factors such as age [
7‐
10], gender [
7], marital status [
11], occupation [
8,
9,
11,
12], workers’ compensation status [
7‐
9,
13‐
17], presence of revision surgery after a previously failed operation [
7], preoperative expectations [
11], postoperative pain [
8,
11,
12,
18,
19] and postoperative range of motion (i.e. internal rotation [
8,
12], anteversion/elevation [
10,
12,
18,
19] had already been identified to influence patient satisfaction after shoulder surgery. However, the majority of the above mentioned studies had substantial limitations in scope and or validity. But there exist a few other studies with excellent quality, which examine determinants of patient satisfaction after surgery in other articulations for example the knee [
20,
21].
Patient satisfaction plays a pivotal and not thoroughly studied role in assessing surgical outcome. The identification of positive and negative predicting factors could lead to preoperative prediction models for determining the probability of an (un-)desired surgical outcome. It appears particularly important also to know parameters, which do not affect patients’ postoperative satisfaction because it may help surgeon and therapist to avoid wasting energy in efforts not leading to improvement of patient satisfaction.
The purpose of this study was to systematically analyse as many allegedly relevant determinants in one evaluation and study their true influence on patient satisfaction following operative treatment of rotator cuff tears or osteoarthritis in a multivariable regression model.
Discussion
Subjective outcome research has become much more relevant over the last decades [
11]. A key capacity of patient satisfaction is the opportunity to critically assess medical outcome or treatment methods. It offers new tools to compare procedures and health care providers or enables the validation of health care quality of an existing environment [
8]. The purpose of this study was to investigate how patient satisfaction after a rotator cuff repair or an implantation of a shoulder arthroplasty is composed and to establish a list with all determinants of ultimate patient satisfaction an orthopaedic surgeon should consider. We confirmed our hypothesis and identified various determinants and score values, which are associated with patient satisfaction.
Despite a rather large study population of 505 patients we are aware of potential limitations of this study. First this is a retrospective study of data, which were prospectively collected in a standardized fashion. Patients who wish or consent to undergo surgery may be more positive than those who have elected not to be operated on and who are not included in this study. Further, we selected patients with complete data sets: this may contain a bias as patients not reporting back may have other perceptions of satisfaction. However, overall satisfaction of our population is compared to other studies rather reduced [
18] and as well to other orthopaedic interventions [
23]. This fact is probably related with the selection criteria because dissatisfied Patient had more frequent consultations and more complete data. Further, we are aware of other potential influencing factors like orthopaedic disease, type of surgery, which we excluded on purpose from the analysis as we really focused on other independent factors influencing the patients satisfaction.
Despite these limitations we were able to identify factors, which showed neither in the multi- nor univariable analysis any influence on patients satisfaction:
Gender does not play a relevant role in the determination of patient satisfaction. This fact is agreed upon in the orthopaedic literature for rotator cuff repairs [
9,
11,
12,
24], implantations of hemi- and total arthroplasties [
8] or shoulder stabilisations [
19,
25]. In addition, our findings are in accordance with the results of the study of Tashjian et al. [
11], which shows that
marital status is not a relevant determinant of patient satisfaction after rotator cuff repair. Furthermore, we found in our evaluation that the
affected side, the
dominance, the case of
both shoulders affected or the
nature of the injury does not play a decisive role for the patients’ postoperative satisfaction. This result corresponds with the result of Kim et al. [
9] concerning the determinant dominance of the affected shoulder.
It has been postulated in literature that psychosocial factors, especially preoperative psychological distress, such as depression, is associated with poor clinical outcome [
26‐
28]. We have tried to incorporate various psychiatric diagnoses in a single variable and investigated the effect of psychotropic drugs on patient postoperative satisfaction. A correlation between those variables could, however, not be confirmed in our evaluation. In addition, we scrutinized the potential effect of different
chronic comorbidities. In accordance with the results of Tashjian et al. [
11] and Jacobs et al. [
18] we were unable to find a correlation. Pursuant to our knowledge, this is the first study, which has analysed specific determinants like the presence of
immunosuppressive medication or
non-orthopaedic previous surgeries. However, none of these determinants showed an influence on the resulting satisfaction.
Despite all other sub-values of the postoperative Constant score, neither
postoperative internal- nor external rotation showed a correlation with higher patient satisfaction. Although previous reports did show a positive correlation between internal rotation and patients satisfaction [
8,
12], postoperative external rotation was also found to be of little importance regarding patients satisfaction [
12,
18,
19]. A possible explanation for the unexpectedly missing correlation between patients’ satisfaction and internal and external rotation might be the fact, that it is not the maximum amount of rotation but the absence of a necessary minimal achievement, which indisputably will influence patient satisfaction.
Furthermore this investigation revealed factors, which seem to have some influence on patients satisfaction (significant influence in univariable analysis) but might be confounded and influenced by other factors (no significant influence in multivariable analysis):
Age as a determinant is being discussed very controversially in the orthopaedic literature. Our results indicate a higher satisfaction of older patients, which is in accordance to the results of Chen et al. [
8] and Kim et al. [
9] for shoulder arthroplasties and rotator cuff repairs. Watson et al. [
7] proposes that younger patients have higher demands and expectations of their shoulder and are therefore more easily dissatisfied with imperfect healing. There is, however also a number of publications, which deny a correlation between increasing age and higher patient satisfaction [
12,
14,
19,
24,
25].
In our study, patients with a private health care insurance reached a significantly higher patient satisfaction than patients with a statutory health insurance. Furthermore, patients receiving treatment by the chief of the department seem to reach a higher satisfaction level than patients treated by (senior) consultants.
Our finding that
employed and retired patients tend to be more satisfied than
unemployed and disabled patients are in accordance with the results of the studies by Kim et al. [
9] and Tashjian et al. [
11]. Furthermore our data confirms the often reported correlation between
workers’ compensation claims and a lower patient satisfaction [
7‐
9,
13‐
17,
29,
30]. Also
postoperative anteversion/elevation is an established determinant of the patient satisfaction in the orthopaedic literature [
10,
12,
18,
19]. The results of our evaluation further support this correlation.
Also chronic alcohol abuse or a history of smoking (more than 10 pack-years) was associated with a low patient satisfaction. The later finding is contrary to the findings of Tashjian et al. [
11]. A possible explanation for our result is the known impaired healing potential and the diminished collagen production of a chronic smoker [
31‐
33].
Finally we were able to identify factors, which turned out to independently influence patients’ satisfaction (significant correlation in uni- and multivariable analysis):
As expected, remaining
pain was identified to negatively influence patient satisfaction. This is in consensus to other published results for various shoulder interventions [
8,
11,
12,
18,
19]. Our retrospective data analysis makes it however impossible to analyse the interesting question regarding the influence of peri- or immediate postoperative pain on the long-term outcome.
Furthermore the presence of peri- or postoperative complications affects patient satisfaction negatively, which is not unexpected, but to our knowledge so far unreported in the literature. In addition to that we analysed the influence of needed revision surgery, which negatively influenced patients satisfaction in the univariable analysis but showed only a trend (p = 0.062) in multivariable analysis.
Postoperative abduction was the only subvalue of the Constant Score, which turned out to independently positive influence patient satisfaction. This correlation seems to be unreported so far in orthopaedic literature and we should possibly focus even more on this determinant in postoperative rehabilitation.
The distinct correlation between patient satisfaction and the postoperative subjective shoulder value supports the validity of this analysis and clarifies the resemblance between these two subjective outcome parameters.
Conclusion
This investigation establishes that the absence of perioperative complication, excellent control of postoperative pain, surprisingly active abduction in the scapular plane (not elevation!) are associated with high patient satisfaction after rotator cuff repair or shoulder arthroplasty. It is, however, particularly important, that factors such as retirement, light physical work, private health insurance status, non-smoking, absence of chronic alcohol abuse, older age or receiving treatment by the chief of the department, were correlated with higher patient satisfaction independent of the pathology and type of surgery. On the other hand our results document that in view of patient satisfaction the patients’ gender, marital status, dominance of the shoulder, nature of the injury, previous general operations, comorbidities, diabetes mellitus, psychotropic drugs or immunosuppressive medication are not associated with the ultimate subjective result. These findings may help to inform patients on their risks, to select patients for surgery and to focus peri- and postoperative treatment on the few modifiable factors identified to increase patient satisfaction.