Hospital for Special Surgery Perspectives

Patient Satisfaction and Health Outcomes in Sports Medicine

Anya Romanowski, MS, RD


April 06, 2017

Editorial Collaboration

Medscape &


Medscape interviewed Benedict Nwachukwu, MD, MBA, a fourth-year orthopedic resident at the Hospital for Special Surgery (HSS) in New York City, who is pursuing a fellowship and specialization in sports medicine. In addition, he is interested in health services and health outcomes research.

Benedict Nwachukwu, MD, MBA

Dr Nwachukwu recently attended and presented several lectures on patient satisfaction and outcome improvement in orthopedic surgery at the American Academy of Orthopaedic Surgeons Annual Meeting in San Diego, California.

Medscape: What led you to conduct research on patient satisfaction and health outcomes in orthopedics?

Dr Nwachukwu: I've been fortunate to have a background in working with mentors at Harvard Medical School, where I did my medical school training; there, I was introduced to health services and health outcomes research. I've been able to continue that at the HSS, and I've been working with the registries at the hospital, looking at some of the outcomes here.

Athletic Patients' Satisfaction With ACL Reconstruction Surgery

Medscape: The first study I would like to discuss today is on athletic patients and their satisfaction with anterior cruciate ligament (ACL) surgery. Can you talk about your findings?

Dr Nwachukwu: Yes, absolutely. We looked at the ACL registry at the HSS, and we looked specifically at competitive athletes. Return to play has been understudied, and it's a very important outcome because if you're an athlete, you want to get back to playing. That's the reason why you do the surgery.

We looked at the proportion of patients who were able to return to the sport they played before injury, and the number of patients who were satisfied. We found a high rate of return to play (87%) and a high rate of satisfaction (over 80% said that they were very satisfied), and 98% of the patients said that they would have surgery again if they needed to. Of note, we found that return to play was correlated with patient satisfaction. It seems as though for patients who are able to return to their sport, they're more likely to be happy, which is an important finding.

Medscape: With regard to this satisfaction, did you find any differences in terms of gender or age?

Dr Nwachukwu: We didn't find any gender-specific differences, but we did find other important differences. We found that surgical technique did matter, at least in our data set. Patients who had surgery with bone, tendon-bone patellar autograft, were more likely to return to play.

We also found that the sport the athlete played also affected their likelihood to return to play. Soccer and lacrosse players were less likely to return to play.

There are a number of reasons you could hypothesize as to why that is. It could be because those sports involve more rigorous cutting activities, and attention is not being paid to postoperatively rehabilitating those patients to their specific sport demand. I think this is an area that warrants particular future study.

Medscape: There's been a push to send patients home earlier after surgeries. Have you found the length and type of rehabilitation to have an effect on their recovery, and how quickly they get back to playing their sport?

Dr Nwachukwu: Yes; that's a very interesting area. There hasn't been a lot of study on the rehab process and postsurgical recovery. We did not specifically look at that in the study, but on the basis of the sport differences that we found, I think that there is potentially a role to tailor rehab. A soccer player should get different rehab from that provided to a football or a basketball player, and I think that would potentially have an impact on their outcome and maybe even their satisfaction.

Surgeon Reviews on Physician Ratings Websites

Medscape: One of your other studies looked at doctor reviews on various websites. I am sure surgeons would be interested in knowing more about what influences a patient when they rate a surgeon. What does your study glean for us?

Dr Nwachukwu: This study pertained specifically to sports medicine surgeons. We looked at how sports medicine surgeons are rated on the three websites that we identified as potentially being the most high-volume online rating websites: RateMDs, Healthgrades, and Vitals. We chose sports medicine because it is a highly elective field, and so there's a lot of pressure for patients to be satisfied and for surgeons to provide the appropriate care.

One of the things that we found was that there was a relatively low degree of consistency among the websites. We found that for the surgeons who were rated the highest—4.5 out of 5—there was a little bit more consistency for those surgeons across websites, but for the lower-rated surgeons, there was less consistency. We found that on one website, a patient might give a surgeon a low rating, which may skew the surgeon's rating on that one website. Yet, they may still have moderate or high ratings on other websites.

So in the future, there's potentially an opportunity for a mechanism to aggregate ratings across one website so that the patient pool isn't being diluted, and patients would go to one website to rate surgeons.

Medscape: And as far as the ratings are concerned, did you find that one tends to be better at rating the physicians or surgeons, specifically orthopedic surgeons?

Dr Nwachukwu: We didn't look to see which website was better or worse per se. We did find that there tended to be more ratings on Healthgrades, and we were able to do a more robust analysis of the Healthgrades predictor.

We found that female surgeons were more likely to get high ratings on Healthgrades. We also found that surgeons who had fewer years in practice were more likely to get high ratings.

Medscape: It's interesting that patients rely on these rating websites rather than visiting the official hospital websites, where they can obtain more information about the physician or surgeon. The hospital websites provide not just faculty bios but also lists their research, areas of specialty, and any awards they have won.

Dr Nwachukwu: Absolutely.

Treating Hip Impingement in Adolescents and Adults

Medscape: You were also involved in another study on outcome improvements and treating femoroacetabular impingement in adolescents. Could you describe this study?

Dr Nwachukwu: Yes. Femoroacetabular impingement, commonly referred to as "FAI," is now a well-recognized clinical entity that can cause disability and limited function in children as well as adults. We have a relatively good understanding of how our adult patients are doing and what outcome scores they need to achieve to have meaningful outcome improvement, but we don't really understand what that is for children.

In the study, we looked at children who had surgery at HSS; we used the hospital's hip preservation registry to identify these children. We looked at the outcome measures that they had achieved at 1 year, and we looked at the way in which they responded to questions. Specifically, there was an anchor question that we asked at 1-year follow up: "Since your hip arthroscopy, how would you rate your physical function?" The children could respond with "no change," "much improved," "a little bit improved," or "worse." We found that the majority of children reported being "much improved."

We then used the responses to those questions to derive what are called "minimal clinically important difference" and "substantial clinical benefit." We found that not only do most of these children achieve these important clinical outcome improvements, but the improvements are actually greater than what adults achieve. The way we interpreted that finding is that a large percentage of children do well, but a large improvement is needed for a pediatric patient to perceive important clinical improvement.

Medscape: Are there any other studies that you would like to share with us today?

Dr Nwachukwu: In addition to reporting our outcomes for children, we are also reporting our outcomes of hip arthroscopy in adults. These studies go hand in hand, where we're showing that adult patients do well after hip arthroscopy. In addition, we identify important preoperative thresholds and outcome scores that are predictive of doing well postoperatively.

I think that this is an important area going forward. As we improve our predictive capabilities in medicine, we want to be able to tell a patient preoperatively, "This is your level of function" and "This is how much better we can potentially make you after surgery," or "You're doing so well that maybe you may not benefit as much from surgery, and you may consider doing more physical therapy or other nonoperative modalities."

Disclosure: Benedict Nwachukwu, MD, MBA, has disclosed no relevant financial relationships.


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