Date of Award

January 2022

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Jonathan N. Grauer


Introduction: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a federally mandated survey that assesses patient satisfaction after hospitalization. It has been noted that a minority of patients actually return the survey. Potential bias in who does and does not respond to the survey (nonresponse bias) after total joint arthroplasty (TJA) may affect the survey results. Thus, the objective of this thesis is to assess the relationship between patient characteristics and postoperative outcomes on HCAHPS survey nonresponse among patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods: All adult patients at a single institution undergoing inpatient, elective, primary THA and TKA between February 2013 and May 2020 were selected for analysis. Following discharge, all patients were mailed the HCAHPS survey. The primary outcome analyzed in this thesis is survey return. Patient characteristics, surgical variables, and 30-day postoperative outcomes were analyzed. Univariate and multivariate analyses were performed to identify factors independently associated with return of the HCAHPS survey.

Results: In total, 3,310 THA patients were identified, of which HCAHPS surveys were returned by 1,049 (31.69%). Similarly, 4,804 TKA patients were identified, of which HCAHPS surveys were returned by 1,498 (31.22%). On multivariate regression analyses, patients from both study cohorts who did not return the survey were more likely to: have a higher American Society of Anesthesia score (THA cohort: score of three or higher, odds ratio [OR] = 2.27, P < 0.001; TKA cohort: OR = 2.37, P<0.001), be partially or totally dependent (THA cohort: OR = 2.69, P = 0.005; TKA cohort: OR = 2.37, P = 0.037), experience readmission (THA cohort: OR = 2.13, P < 0.001; TKA cohort: OR = OR = 1.94; P < 0.001), be discharged to a place other than home (THA cohort: OR = 1.71, P < 0.001; TKA cohort: OR = 1.52, P<0.001), or stay in the hospital for longer than 3 days (THA cohort: OR = 1.89, P < 0.001; TKA cohort: OR = 1.43; P = 0.004). THA cohort nonresponders were also more likely to be Black/African American (OR = 3.40; P < 0.001).

Conclusion: This thesis demonstrates that after TJA, the HCAHPS survey response rate was only 31% and completion of the survey correlated with demographic and perioperative variables. These findings suggest that the HCAHPS survey results should be interpreted as a skewed sample of the true surgical patient population. Nonresponse bias is an important factor to consider when evaluating healthcare quality, patient satisfaction survey results, and their effects on federal hospital reimbursement.


This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.