Severity of Postoperative Complications From the Perspective of the Patient

Abstract

Background: Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.

Objective: To assess patient-rated complication severity and determine concordance with existing grading systems.

Methods: A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.

Results: One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.

Conclusion: Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

Keywords: communication; patient expectations; patient perspectives/narratives; quantitative methods; survey data.

Figure 1.

Patient-rated severity scores for hypothetical postoperative events by Accordion grades. Box-and-whisker plots display the distribution of raw severity scores pooled from patient responses to both survey versions and categorized by grade. Mean severity scores are represented by the central black dots connected by a black line. See “Methods” section for analysis methods. All grades and one postoperative event that did not meet criteria for grading as a complication (“no grade”) were rated significantly different from each (P < .05) other unless noted as “NS” (not significant). The ungraded postoperative event described a hypothetical patient who was weakened by an operation for colon cancer, needed significant help from his family and friends after returning home after surgery, and was unable to stay at home alone. It was specified that the patient required 10 weeks to regain his normal amount of strength. This “no grade” complication was scored significantly higher in severity than all other grades (P < .001), with the exception of grade 4 (P = .08). Since version 2 contained the only grade 5 and ungraded complications, it was used alone to compare all grades. Versions 1 and 2 of the surveys were analyzed for grades 1 to 4 both independently and pooled, demonstrating a pattern and significance consistent with the results for version 2 alone.

Figure 2.

Variation in patient-rated severity scores within individual Accordion grades. A, Box-and-whisker plots of the distributions of patient-rated severity scores for each individual complication representing Accordion grades 2, 3, and 4 are shown. Patients scored complications using a qualitative scale of severity from 0 to 100, represented on the x-axis. Each box plot represents the range of severity score values for a single complication. The colored boxes represent the first to the third quartiles, with a central line representing the median. Outliers were determined as being >1.5 × interquartile range (IQR) above the third quartile and are represented by dots. See “Methods” section for analysis methods. B, Grade 1 complication scenarios in the survey featured the same complication with a different duration to assess the importance of time to patients. The complications of an NG tube placement, wound care requiring dressing changes, and Foley catheter placement were presented with varying times of duration. Box-and-whisker plots of the distribution of scores for each complication are shown, with means indicated by the central dots connected by a line. *P ≤ .05, **P ≤ .01, ***P ≤ .001. NS indicates not significant.

Figure 3.

The highest and lowest patient-rated severity of brief postoperative events. Patients were asked to score 18 brief events according to a 5-point scale, rating each complication by how likely it would make them think of the problem as “severe.” Responses were ranked according to percentage rating the events as the most severe (ie, “A Great Deal”). The top and bottom 5 ranked events are presented above. The Accordion grades of each event are provided here but were not specified to the survey respondents.