SCIENCE TIMES

2. Kantelhardt SR, Martinez R, Baerwinkel S, Burger R,

Giese A, Rohde V. Perioperative course and accuracy
of screw positioning in conventional, open robotic-guided and percutaneous robotic-guided, pedicle
screw placement. Eur Spine J. 2011;20(6):860-868.
3. Devito DP, Kaplan L, Dietl R, Pfeiffer M, Horne D,
Silberstein B, et al. Clinical acceptance and accuracy
assessment of spinal implants guided with SpineAssist
surgical robot: retrospective study. Spine (Phila Pa
1976). 2010;35(24):2109-2115.

HCAHPS Replaces Press

Ganey Survey as Quality
Measure for Patient
Hospital Experience

Figure 2. 2011 Mazor Robotics Ltd. All rights reserved with non-exclusive
permission.

increased screw accuracy to 94.5% from 91.5%

using conventional techniques.2 Other retrospective reports have shown even higher accuracy with Devito et al reporting a 98.3% good
placement (Gertzbein Robbins A and B) in 646
screws.3 Interestingly they also reported a successful execution rate of the robot only
ranging from 83% to 90% depending on where
in the learning curve the cases were performed.
The authors of the current study also highlight limitations of the system that may help
explain the low accuracy provided by robotic
assistance in this study. First, there are several
techniques available to fixate the robot to the
patient. In this study the authors utilized the
bed mount option where the robot is only
attached to the patient by a single K-wire which
they speculate may allow for movement of the
system relative to the patient. Furthermore all
screws were placed through a paramedian,
Wiltse-type approach with blunt perforation
of the paraspinal musculature by the cannula.
The authors note that with this technique any
firm muscle bundles could lead to deflection of
the cannula. Likewise facet joint hypertrophy

NEUROSURGERY

with a steep facet can give rise to lateral skidding

of the cannula at the pedicle screw entrance
point. All of these factors may influence the
accuracy of the system and should be considered
when utilizing the system.
In conclusion, the use of robotic assistance for
pedicle screw placement has been gaining clinical
acceptance in select sites throughout the United
States and Europe. With this increased utilization the generation of outcome data has also
been accumulating, albeit slowly. The study by
Ringel is the first prospective randomized trial of
the technology and indicates that, using the
techniques employed in this trial, the robotic
assistance led to significantly decreased pedicle
screw placement accuracy.
K.S. CAHILL
M.Y. WANG

REFERENCES
1. Ringel F, Stuer C, Reinke A, et al. Accuracy of
robot-assisted placement of lumbar and sacral pedicle
screws: a prospective randomized comparison to
conventional freehand screw implantation. Spine
(Phila Pa 1976). 2012;37(8):E496-E501.

eginning in just a few months, hospital

patient satisfaction scores will have
a direct impact on the bottom line for
health care reimbursement. In October 2012,
the Center for Medicare and Medicaid Services
(CMS) is reducing by 1% the base operating
diagnosis-related group (DRG) payments to
hospitals to create an incentive fund, estimated
at $850 million.1 How this money is distributed
to hospitals will depend on their performance
on several quality measures, 30% of which
will be based on how patients rate their hospital
experience on the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) patient satisfaction survey. The
component of payment to hospitals, which is
variable and based on performance measures, is
expected to gradually increase over the next
several years, and private payers are likely to
follow suit.1
This so-called value-based purchasing initiative is now required under the Patient Protection and Affordable Care Act, the 2010
national health-care reform legislation. The
patient satisfaction survey tool selected for
value-based purchasing, HCAHPS, is available
for distribution through many authorized vendors including Press Ganey Associates, Inc.,
which previously distributed its own proprietary
survey to 40% of United States hospitals. The
HCAHPS survey is designed to allow consumers
to rate their inpatient experiences and perception
of care and is anticipated to be an improvement
over the highly criticized Press Ganey Patient
Satisfaction Survey. Because HCAHPS has
been selected by CMS as the validated and
transparent national survey tool with publicly
available results at the Hospital Compare
website, (www.hospitalcompare.hhs.gov) these
data can then be used to evaluate hospitals,
improve patient decision-making and increase

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SCIENCE TIMES

Figure 1. Patient Survey (http-//www.britcaymen.com/wp-content/uploads/

2011/08/istock-HCAHPS-survey).

incentives for hospitals and providers to deliver

what patients perceive as high-quality care.2
The inclusion of patient satisfaction scores in
the reimbursement equations, however, presents
a number of challenges. Based on concerns about
Press Ganey and other available survey tools,
researchers have been encouraged to analyze
HCAHPS to identify potential biases, and
CMS is considering using conversion factors to
normalize the national data where biases have
been identified.
Aside from reporting bias, the question of
whether patient satisfaction surveys are a useful
tool upon which to make administrative or
medical decisions remains. Among the concerns
are that patients may not be in the best position
to evaluate their care, and that hospitals may not
be able to improve health-care delivery based on
results of patient surveys. In addition, some
critics argue that the surveys do not adequately
take into account variables that can skew results
against academic medical centers or hospitals in
regions of the country that treat large numbers of
patients with mental or other serious illnesses.3
Perhaps most concerning is new data that
suggests that higher hospital patient satisfaction
scores are actually associated with higher inpatient
use, overall health care and prescription drug

expenditures and increased mortality. In a recent

article published in Archives of Internal Medicine
Joshua J. Fenton of the University of California
Davis Health System evaluated data from more
than 50 000 adult respondents of the Medical
Expenditure Panel Survey, a nationally representative survey of the US population that assesses the
use and costs of medical services. Respondents
completed questionnaires about their health status
and experiences with health care, including how
often their health-care providers listened carefully,
were respectful and spent enough time with them.
Participants also were asked to rate their health
care on a scale of 0 to 10. The data were linked to
the national death certificate registry.
What Fenton and colleagues found was that
even after adjusting for numerous variables,
patients who were most satisfied had greater
chances of being admitted to the hospital and
had about 9% higher total health-care costs as
well as 9% higher prescription drug expenditures. Most strikingly, death rates were also
higher. For every 100 people who died over an
average period of nearly 4 years in the least
satisfied group, about 126 people died in the
most satisfied group. More satisfied patients had
better average physical and mental health status
at baseline than less satisfied patients. The

Figure 2. Brenda E. Sirovich, Invited Commentary, How to feed and grow your
health care system, Archives of Internal Medicine, Vol 172(No. 5), March
12,2012.

N22 | VOLUME 71 | NUMBER 2 | AUGUST 2012

association between high patient satisfaction

and an increased risk of dying was also stronger
among healthier patients.4 An alternative explanation for this unexpected finding, likely based
on surveys completed by family members of the
deceased patients, may reflect the perception
that everything possible was done to help their
loved ones. As health-care providers, we may be
very good at focusing attention on and communicating well with this patient population
and their families.
In an accompanying editorial in the same
journal, Brenda E. Sirovich, MD, MS, of the
Department of Veterans Affairs Medical Center
in Virginia, explains that the Fenton research
infers that efforts to cater to patient satisfaction
may be ill guided because by implicitly encouraging health care providers to honor requests for
(or to explicitly offer) discretionary health care
services, such efforts may lead to overutilization,
higher costs, and worse outcomes.5
The author further suggests that while the
relationship between customer satisfaction and
subsequent consumption in the business world is
doctrine, it is not necessarily appropriate in health
care. While most Americans may accurately
assess how well their washing machines, their
hairdressers, or even their airlines are performing, their evaluations of physicians and health
care interventions may have limited validity,
she writes.
These and other pitfalls of patient satisfaction
surveys and their increasing use in physician
compensation and hospital reimbursement for
care are important for neurosurgeons and all
physicians to consider as these measurement
tools seemingly affect every aspect of the services
we provide.
In one online survey posted by Emergency
Physician Monthly, 16% of the 717 medical
professionals who responded said they had their
employment threatened by low patient satisfaction scores, and 27% stated that their income
was in some way tied to satisfaction scores.6
In addition to the effect of patient satisfaction
scores on physician employment and income,
the authors, William Sullivan, DO and JD, and
Joe DeLucia, DO, explain that low survey scores
can affect medical care, and not always for the
benefit of the patient. When asked to rate on a 1
to 10 scale how patient satisfaction scoring
affects the amount of testing performed, 41%
of respondents said they decreased the amount,
while 59% said they increased testing. Additionally, 48% of health-care providers reported
altering medical treatmentincluding providing unnecessary carein an effort to influence
a patient satisfaction survey. Adverse outcomes
from treatment rendered due to patient survey

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SCIENCE TIMES

Figure 3. Summary of mailed HCAHPS Patient Satisfaction Survey. http://www.hcahpsonline.org/surveyinstrument.aspx.

concerns included allergic reactions to medications, resistant bacterial infections, kidney

damage and medication overdose.6 These
authors go on to theorize that hospital liability
could increase from the effects of these scores.
If adverse patient outcomes due to unnecessary
medical treatment can be tied to pressures that
hospitals place on the medical staff to improve
patient satisfaction scores, civil liability to the
hospital could result.
By examining the flaws in Press Ganeys
approach to patient satisfaction measurement
and reporting, physicians and hospitals can be
more informed users of HCAHPS. For example, according to Press Ganey, a minimum of 30
survey responses collected over the designated
time period is necessary to draw meaningful
conclusions of the data for a specific individual,
program or hospital. Despite this requirement
to achieve statistical significance, Sullivan and

NEUROSURGERY

DeLucia found that the firm often provides

comparative data about hospital departments
and individual physicians based on a smaller
sample size that may create an unacceptably
large margin of error.6 Sullivan, for example,
said his department may have 8 to 10 Press
Ganey survey responses per month and yet still
receives monthly reports from the company
analyzing the data. Because of the small sample
size, 1 month his department ranked in the first
percentile and 2 months later it ranked in the
99th percentile.6
The authors further point out that emergency
patients who are admittedthose most in need
of emergency caredo not receive Press Ganey
surveys about their ER experience of care. These
are the patients who likely had the most
thorough evaluation and possibly, the most
heroic and excellent care. Those who are treated
in the ER and discharged, and may have had to

wait longer because of triaging protocols, are

likely those to have the least satisfactory
experiences. But only the individuals who are
not admitted to the hospital are evaluated on
Press Ganey Surveys for ER.
Whether patient satisfaction surveys actually
measure satisfaction has been questioned.
Patient motivation to fill out a survey can skew
results, since it may be those who had an extreme
experienceeither superb or terriblewho are
likely to bother. How a survey is administered
can also affect the patients evaluation.7 In
a study funded by CMS, researchers found that
patients randomized to the telephone and active
interactive voice response modes provided more
positive evaluations than patients randomized
to mail and mixed-mailed survey with phone
call follow up.7
Patient satisfaction scores are being used to
measure quality of care, but patients may not be

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SCIENCE TIMES

in the best position to evaluate their care, and

hospitals may not be able to improve health-care
delivery based on results of patient surveys.
Geographical, cultural and racial differences
can affect a patients perspective about their
medical or hospital experiences. Research
aimed specifically at identifying biases in the
HCAHPS reporting system has already found
that hospital rankings vary substantially by
patient health status and ethnicity/language
and moderately by patient education and age
(P , .05).8 Because HCAHPS largely rates
patients perception of their hospital care, there
is concern regarding higher scores in more
affluent communities where supplemental services and philanthropy dollars may be available
to improve the patient experience.2 One
Cleveland Clinic study evaluating bias in
HCAHPS reporting, found that no hospital
in the nation with 500 or more beds has scored
in the 90th percentile for such basic measures as
physician or nurse communication.3 Vinski
et al identified yet another variable potentially,
out of our control to change, which lowers
patient satisfaction scoreswhether a patient is
in isolation for infection.9
Research has described how patients opinions of the care they receive can be different
from the actual quality of the medical care they
receive, and that opinions and experiences vary
by race.10 In a randomized controlled trial,
researchers from Mount Sinai school of Medicine and Columbia University Medical Center
surveyed inner-city women with newly diagnosed and surgically treated early-stage breast
cancer for their perceived quality of care and the
process of getting care including referrals, test
results, and treatments. They compared the
responses to patient records to determine the
actual quality of care.
Of the 374 women who had received
treatment for early stage breast cancer, 55%
said they received excellent care, but most
88%actually got care that was in line with
the best current treatment guidelines. Among
the other findings: African-American women
were less likely to report excellent care than
Caucasian or Hispanic women, less likely to
trust their doctor, and more likely to say they
experienced bias during the process. However,
there was no difference in actual quality of care
received in any group.
Geographic differences may also play a role in
how patients perceive their care experience.
Modern Healthcare reported that HCAHPS
survey results indicate patients favor smaller,
rural hospitals. One Alabama hospital official
interviewed said his facility may have ranked
highly because it encourages its employees to

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practice their faith with patients, which is wellreceived by and mentioned in survey responses
by patients.11 Overall, there is a perception that
a typical patient, based on acuity, diagnosis or
demographics at an institution will report the
highest patient satisfaction scores.
It is not clear yet whether HCAHPS will use
a qualitative threshold score to influence funding
decisions, or whether they will replicate the
flawed statistical process of Press Ganey by using
percentiles. Robert C Lloyd, Ph.D, author of
Quality Health Care: A Guide to Developing
and Using Indicators12 is among the statisticians
who helped develop the percentile statistical
analysis mapping that, in 1985, was based on
a classic bell-shaped distribution of patient
satisfaction survey scores.
Lloyd explained that because hospitals, medical groups and physicians have been working
hard these past 20 years to achieve higher Press
Ganey scores, there is now a significant clustering of raw scores at the high end with a very
narrow response range. The data no longer have
the bell-shaped distribution, and when this nowcondensed data distribution maps to the percentile spectrum, the percentile data are highly
inaccurate. A difference of 20 or 30 percentile
points may actually be based on raw scores that
are not statistically different and simply the result
of random variation, yet these percentile results
sometimes announced at staff meetings and
posted in physician lounges are also used to
determine bonus pay for clinicians and promote
or replace program managers.13
Physicians and other providers should be aware
of the limitations identified in using Press Ganey
and the biases inherent with any patient satisfaction survey methodology. With this knowledge,
strategies can be developed to avoid the same
misleading analyses with the new HCAHPS
survey so that physician pay, institutional
reimbursement and hiring and firing of managers
are based on real and meaningful changes in
patients perception of their health-care experience, and the quality of care provided.
EDIE E. ZUSMAN

REFERENCES
1. Rau J. Medicare to begin basing hospital payments on
patient-satisfaction scores. Kaiser Health News. April
28, 2011. Available at: http://www.kaiserhealthnews.
org/stories/2011/april/28/medicare-hospital-patientsatisfaction.aspx.
2. Giordano LA, Elliott MN, Goldstein E,
Lehrman WG, Spencer PA. Development, implementation, and public reporting of the HCAHPS
survey. Med Care Res Rev. 2010;67(1):27-37.
3. Daly R. Unsatisfactory marks. Hospitals question
use of HCAHPS in scoring for value-based purchasing. Mod Healthc. 2011;41(33):30.

4. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost

of satisfaction: a national study of patient satisfaction,
health care utilization, expenditures, and mortality.
Arch Intern Med. 2012;172(5):405-411.
5. Sirovich BE. How to feed and grow your health care
system: comment on "The cost of satisfaction". Arch
Intern Med. 2012;172(5):411-413.
6. Sullivan W, DeLucia J. 2127? Seven things you
may not know about Press Ganey Statistics. Emergency Physicians Monthly. September 22, 2010.
Available at: http://www.epmonthly.com/archives/
features/227-seven-things-you-may-not-know-aboutpress-gainey-statistics/.
7. Elliott MN, Zaslavsky AM, Goldstein E, et al.
Effects of survey mode, patient mix, and nonresponse on CAHPS hospital survey scores. Health
Serv Res. 2009;44(2 pt 1):501-518.
8. Elliott MN, Lehrman WG, Goldstein E,
Hambarsoomian K, Beckett MK, Giordano LA.
Do hospitals rank differently on HCAHPS for
different patient subgroups? Med Care Res Rev.
2010;67(1):56-73.
9. Vinski J, Bertin M, Sun Z, et al. Impact of isolation
on hospital consumer assessment of healthcare
providers and systems scores: is isolation isolating?
Infect Control Hosp Epidemiol. 2012;33(5):
513-516.
10. Bickell NA, Neuman J, Fei K, Franco R, Joseph KA.
Quality of breast cancer care: perception versus
practice. J Clin Oncol. 2012;30(15):1791-1795.
11. DerGurahian J. Southern comfort. HCAHPS data
favors Ala. hospitals. Mod Healthc. 2008;38(14):10.
12. Lloyd R. Quality Health Care: A Guide to Developing
and Using Indicators. Sudbury, Massachusetts: Jones
& Bartlet Learning; 2004.
13. Lloyd R. Statistics for Managers Sutter Health
Management for Clinical Excellence Course. Green
Valley, CA: Sutter Health; 2012.

Deep Brain Stimulation

of Entorhinal Cortex
Shows Early Promise for
Enhancement of Memory
Function

emory loss and the inability to form

new memories properly is a prominent and devastating feature of many
widespread neurological conditions, particularly
Alzheimers disease and other forms of dementia. Memory function is supported by the limbic
system, and more specifically the ability to
remember recent events requires the hippocampus and associated structures including the
entorhinal, perirhinal, and parahippocampal
cortices. In rodent models, scientists have found
that direct electrical stimulation of the perforant
pathway, which arises from the entorhinal
cortex in the medial temporal lobe and projects
to the hippocampus, results in the cellular

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