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Determinants of Patient Satisfaction After Severe Lower-Extremity Injuries
Robert V. O'Toole, MD1; Renan C. Castillo, MS2; Andrew N. Pollak, MD1; Ellen J. MacKenzie, PhD2; Michael J. Bosse, MD3
1 Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, T3R62, Baltimore, MD 21201. E-mail address for R.V. O'Toole: rvo3@yahoo.com
2 Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205
3 Carolinas Medical Center, 100 Blythe Boulevard, Charlotte, NC 28203
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (ROI-AR42659) and the Orthopaedic Trauma Association, and less than $10,000 from the Johns Hopkins Center for Injury Research and Policy (R49/CE00198). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, and the Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jun 01;90(6):1206-1211. doi: 10.2106/JBJS.G.00492
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Background: In health care, increased emphasis has been placed on patient-centered care, but to our knowledge little work has been conducted to understand the influences on patient satisfaction after surgery for the treatment of severe lower-extremity injury. Our purpose was to analyze how the patient's satisfaction with the outcome correlates with other measures of outcome (clinical, functional, physical impairment, psychological impairment, and pain) and with the sociodemographic characteristics of the patient, the nature of the injury, and the treatment decisions.

Methods: Four hundred and sixty-three patients treated for limb-threatening lower-extremity injuries at eight level-I trauma centers were followed prospectively. Multivariate regression techniques were used to identify factors correlating with variation in patient self-reported satisfaction at two years after the injury. The outcomes that were tested in the model were pain, range of motion, muscle strength, self-selected walking speed, depression, anxiety, the physical and psychosocial scores of the Sickness Impact Profile (SIP), return to work, and the number of major complications. The patient characteristics that were tested in the model were age, sex, education, poverty status, insurance status, occupation, race, personality profile, and medical comorbidities. Injury severity was tested in the model with use of both the Injury Severity Score and a score reflecting the probability of amputation. The treatment decisions that were tested were amputation versus reconstruction and time to treatment.

Results: No patient demographic, treatment, or injury characteristics were found to correlate with patient satisfaction. Only measures of physical function, psychological distress, clinical recovery, and return to work correlated with patient satisfaction at two years. Five of these outcome measures accounted for >35% of the overall variation in patient satisfaction; these were return to work (p < 0.05), depression (p < 0.05), the physical functioning component of the SIP (p < 0.01), self-selected walking speed (p < 0.001), and pain intensity (p < 0.001). The absence of major complications and less anxiety were marginally significant (p < 0.1).

Conclusions: Patient satisfaction after surgical treatment of lower-extremity injury is predicted more by function, pain, and the presence of depression at two years than by any underlying characteristic of the patient, injury, or treatment.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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