Spine Care Providers Research Articles

Training and Credentialing Standards for Minimally Invasive Spinal Surgery Techniques: Results of a Survey

BACKGROUND: The controversy continues on how to best become proficient in contemporary minimally invasive spinal surgery techniques (MISST). Postgraduate training programs typically lag behind the innovation. Other subspecialty spine care providers often compete with spine surgeons particularly when they do not offer the treatments needed by their patients. The public debate centers around who should be taught and credentialed in providing surgical spine care. OBJECTIVES: The purpose of this study was to conduct an opinion survey amongst spine care providers regarding the learning curve of MISST and which credentialing standards should be established. SETTING: Surgeon online opinion survey sent by email, and chat groups in social media networks, including WeChat, WhatsApp, and LinkedIn. METHODS: Surgeons were asked the following questions: 1) Do you think MISS is harder to learn compared to open surgery? 2) Do you perform MISS? 3) What type of MISS do you perform? 4) If you perform endoscopic surgery, which approach(es)/technique(s) do you employ? 5) In your opinion, where does the innovation take place? 6) Where should MISST be taught? 7) Do you think mastering the MISST learning curve and surgeon skill level affect patient outcomes? 8) Which credentialing criteria do you recommend? Demographic data of responding surgeons, including age, postgraduate training and years from graduation, and practice setting, were also obtained. Descriptive statistics were employed to count the responses and compared to the surgeon’s training using statistical package SPSS Version 27.0 (IBM Corporation, Armonk, NY). RESULTS: The online survey was viewed by 806 surgeons, started by 487, and completed by 272, yielding a completion rate of 55.9%. Orthopedic surgeons comprised 52.6% (143/272) of respondents, followed by 46.7% (127/272) neurosurgeons, and 0.7% pain management physicians (2/272). On average, respondents had graduated from a postgraduate training program 15.43 ± 10.13 years. Nearly all respondents employed MISST (252/272; 92.8%) and thought that proficiency in MISST affects patients’ outcomes (270/272; 98.2%). Some 54.1% (146/270) opined that MISS is more challenging to learn than traditional open spine surgery. Preferred credentialing criteria were 1) number of MISST cases (87.5%; 238/272), b) skill level (69.9%; 190/272), and c) proficiency assessment (59.9%; 163/272). A case log review (42.3%; 116/272) or an oral examination (26.1%; 71/272) was not favored by surgeons. Surgeons reported academia (43.4%; 116/267) and private practice (41.2%; 110/267) as the centers of innovation. Only 15.4% (41/267) of respondents opined that industry was the main driver over innovation. LIMITATIONS: Geographical and cultural biases may impact the opinions of responding surgeons. CONCLUSIONS: Respondents preferred case volume, skill level, and proficiency assessment as credentialing criteria. Surgeons expect academic university programs and specialty societies to provide the necessary training in novel MISST while working with governing boards to update the certification programs. KEY WORDS: Surgeon opinion survey, minimally invasive spinal surgery, learning curve, credentialing, teaching standards

Quality and Accuracy of Cervical Radiculopathy-specific Information on the Internet: A Cross-sectional Analysis.

Cross-sectional analysis. This study aimed to evaluate the quality and accuracy of the content surrounding cervical radiculopathy available on the internet. Those experiencing cervical radiculopathy and their families are increasingly browsing the worldwide web for medical information. As the information offered is likely to influence their health care choices, spine care providers must understand the quality and accuracy of that information. Independent searches were conducted on the three most commonly accessed search engines (Google, Yahoo, and Bing) using the keyword "cervical radiculopathy." The searches were performed on June 28th, 2019. The top 50 sites from each search engines were reviewed. The websites were evaluated using quality, accuracy and usability markers. Seventy-seven unique websites were analyzed; 54.5% were physician or medical group professional sites, 20.8% as non-physician, 10.4% as unidentified, 7.8% as academics, and 6.5% were commercial. Accuracy ranged from <25% to >75% were recorded with a mean accuracy of 3.5 signifying 50% to 75% agreement. Overall, website categories had a significant effect on Journal of American Medical Association (JAMA) score, content quality, accuracy, total summary scores, distraction index, reading ease, and grade level (P < 0.05). Academic sites had the highest mean quality content, accuracy and total summary scores. Four of the top five websites with the highest total summary scores were physician driven. On average, Health on the Net code (HONcode) certified websites had lower grade level readability with greater reading ease and higher DISCERN and JAMA scores than uncertified sites (P < 0.05). Despite the wide number of sources available, the quality, accuracy, pertinence, and intelligibility of the information remains highly variable. Clinicians treating patients with cervical radiculopathy should direct them to verifiable sites with regulated information and, where possible, contribute high- quality information to those sites.Level of Evidence: 4.

Virtual Spine: A Novel, International Teleconferencing Program Developed to Increase the Accessibility of Spine Education During the COVID-19 Pandemic

BackgroundThe coronavirus identified in 2019 (COVID-19) pandemic effectively ended all major spine educational conferences in the first half of 2020. In response, the authors formed a “virtual” case-based conference series directed at delivering spine education to health care providers around the world. We herein share the technical logistics, early participant feedback, and future direction of this initiative.MethodsThe Virtual Global Spine Conference (VGSC) was created in April 2020 by a multiinstitutional team of spinal neurosurgeons and a neuroradiologist. Biweekly virtual meetings were established wherein invited national and international spine care providers would deliver case-based presentations on spine and spine surgery−related conditions via teleconferencing. Promotion was coordinated through social media platforms such as Twitter.ResultsVGSC recruited more than 1000 surgeons, trainees, and other specialists, with 50–100 new registrants per week thereafter. An early survey to the participants, with 168 responders, indicated that 92% viewed the content as highly valuable to their practice and 94% would continue participating post COVID-19. Participants from the United States (29%), Middle East (16%), and Europe (12%) comprised the majority of the audience. Approximately 52% were neurosurgeons, 18% orthopedic surgeons, and 6% neuroradiologists. A majority of participants were physicians (55%) and residents/fellows (21%).ConclusionsThe early success of the VGSC reflects a strong interest in spine education despite the COVID-19 pandemic and social distancing guidelines. There is widespread opinion, backed by our own survey results, that many clinicians and trainees want to see “virtual” education continue post COVID-19.

Remote Virtual Spinal Evaluation in the Era of COVID-19.

With the COVID-19 pandemic disrupting many facets of our society, physicians and patients have begun using telemedicine as a platform for the delivery of health care. One of the challenges in implementing telemedicine for the spine care provider is completing a comprehensive spinal examination. Currently, there is no standardized methodology to complete a full spinal examination through telemedicine. We propose a novel, remote spinal examination methodology that is easily implemented through telemedicine, where the patient is an active participant in the successful completion of his or her examination. This type of examination has been validated in a neurology setting. To facilitate the telemedicine visit, we propose that video instruction be shared with the patient prior to the telemedicine visit to increase the efficacy of the examination. Since the issuance of stay-at-home order across the states, many spine practices around the country have rapidly adopted and increased their telemedicine program to continue provide care for patients during COVID-19 pandemic. At a tertiary academic center in a busy metropolitan area, nearly 700 telemedicine visits were successfully conducted during a 4-week period. There were no remote visits being done prior to the shutdown. Implementation of our proposed remote spinal examination has the potential to serve as a guideline for the spine care provider to efficiently assess patients with spine disease using telemedicine. Because these are only suggestions, providers should tailor examination to each individual patient's needs. V. It is likely that physicians will incorporate telemedicine into health care delivery services even after the COVID-19 pandemic subsides because of telemedicine's efficiency in meeting patient needs. Using the standard maneuvers provided in our study, spine care providers can perform a nearly comprehensive spine examination through telemedicine. Further studies will be needed to validate the reproducibility and reliability of our methodology.

Effects of Volitional Spine Stabilization on Trunk Control During Asymmetric Lifting Task in Patients With Recurrent Low Back Pain.

Study Design:Prospective, concurrent-cohort study.Objectives:To determine the effects of volitional preemptive abdominal contraction (VPAC) on trunk control during an asymmetric lift in patients with recurrent low back pain (rLBP) and compare with matched controls.Methods:Thirty-two rLBP patients and 37 healthy controls performed asymmetric lifting with and without VPAC. Trunk, pelvis, and hip biomechanical along with neuromuscular activity parameters were obtained using 3-dimensional motion capture and electromyography system. Hypotheses were tested using analysis of variance.Results:The VPAC resulted in significantly reduced muscle activity across all trunk extensor muscles in both groups (M ± SD, 6.4% ± 8.2% of maximum contraction; P ≤ .005), and reduced trunk side flexion (1.4° ± 5.1° smaller; P ≤ .005) and hip abduction (8.1° ± 21.1° smaller; P ≤ .003). rLBP patients exhibited reduced muscle activity in external oblique (12.3% ± 5.5% of maximum contraction; P ≤ .012), as well as decreased hip flexion (4.7°, P ≤ .008) and hip abduction (5.2°, P ≤ .001) at the final position of lifting in comparison with healthy controls.Conclusions:The results of this study defend the recommendation that the use of a VPAC increase spine stability during an asymmetrical loading task. Our results provide an indication that a VPAC strategy that is achieved during an asymmetric lifting decreases exposure for lumbar spine injury and instability. Spine care providers and ergonomists can use this information when designing neuromuscular control training programs, both for healthy individuals aimed at prevention of injury, as well as those with a history of rLBP, aimed at full functional recovery and protection from future injury.

Validating the Stopping Opioids after Surgery (SOS) score for sustained postoperative prescription opioid use in spine surgical patients

BACKGROUND CONTEXTThe opioid epidemic has increased scrutiny of health-care practices and care episodes, such as surgery, that increase the risk of opioid dependence. The Stopping Opioids after Surgery (SOS) score to predict sustained prescription opioid use was previously developed within a population of patients receiving general surgery, orthopedic, and urologic procedures. Notably, the performance for this score has not been assessed in a spine surgical cohort. PURPOSEWe sought to validate the SOS score in a series of patients undergoing cervical and lumbar spine surgery, including inpatient and outpatient cohorts. STUDY DESIGN/SETTINGRetrospective review at two academic medical centers and three community hospitals. OUTCOME MEASURESSustained prescription opioid use was defined as opioid prescription without interruption for 90 days or longer following surgery. METHODSThe performance of the SOS score was assessed in the study population by calculating the c-statistic, receiver-operating curve, and observed rates of sustained prescription opioid use. RESULTSAmong 7,027 patients included in this study, 2,374 (33.8%) underwent anterior cervical discectomy and fusion and 4,653 (66.2%) underwent surgery for lumbar disc herniation. The median age was 46 (interquartile range=38.0–53.5). Overall, 604 patients (8.6%) had prolonged opioid prescription. The c-statistic of the risk score was 0.764. The sensitivity of the score at the low risk cutoff of 30 was 0.72. At the high-risk cutoff of 60, the specificity was 0.99. The observed risk (95% confidence interval) of prolonged opioid prescription was 3.6% (3.1–4.2) in the low-risk group (scores <30), 17.2% (15.6–18.7) in the intermediate-risk group (scores 30–60), and 46.0% (36.2–55.9) in the high-risk group (scores >60). CONCLUSIONSWe have validated the use of a clinically relevant bedside risk score for sustained prescription opioid use after spine surgery. The score's ease of use, combined with its exceptional performance, renders it a valuable tool for spine care providers in counseling patients and determining appropriate postdischarge management to prevent sustained opioid use.

Saturday, September 29, 2018 9:00 am–10:00 am Impact of Adult Deformity Correction: 262. The effect of surgical alignment on gait complexity in adult deformity patients: a neuromuscular synergy approach

BACKGROUND CONTEXT Adult degenerative scoliosis (ADS) patients frequently suffer from impairments in mobility. Surgical intervention for ADS mostly improves gait, balance and other health-related quality of life scores. Previous literature demonstrates that the central nervous system (CNS) might use an organization of muscle synergies to control a wide range of activities, for example walking. Instead of controlling each muscle individually, the CNS groups the muscles and activates many them with a single control signal. Hence, neuromuscular synergies may indicate the ability of the CNS in generating independent control signals. Less number of muscle synergies during walking emphasizes inability of the CNS to generate as many independent control signals. The higher number of synergies represents the higher gait complexity since more number of control inputs are required to achieve the same task. PURPOSE To compare number of walking muscle synergies in ADS patients both before and 3 months postsurgery. STUDY DESIGN/SETTING A prospective concurrent control cohort study. PATIENT SAMPLE A total of 13 ADS patients. OUTCOME MEASURES Gait complexity by number of muscle synergies. METHODS Clinical gait analysis was performed one week prior and 3 months postsurgery. Five walking trials were performed at comfort speed. Surface electromyography (EMG) electrodes were placed and recorded bilaterally from 16 trunk and lower extremity muscles: external oblique, gluteus maximus, multifidus, erector spinae, rectus femoris, semitendinosus, tibialis anterior, medial gastrocnemius. EMG data was collected at 2,000 Hz, filtered, rectified, and normalized. The processed EMG was mathematically broken into synergies and their activation ratio (from 100%). The higher number of synergies always reduces the residual error between the reconstructed EMG and the original EMG. The required number of synergies were defined as the minimum number of synergies that could reconstruct EMG signals with subtracting 5% error ([EMGoriginal -EMGreconstructed] = e, e/EMGoriginal RESULTS Clinical gait analysis was performed one week prior and 3 months postsurgery. Five walking trials were performed at comfort speed. Surface electromyography (EMG) electrodes were placed and recorded bilaterally from 16 trunk and lower extremity muscles: external oblique, gluteus maximus, multifidus, erector spinae, rectus femoris, semitendinosus, tibialis anterior and medial gastrocnemius. EMG data was collected at 2,000 Hz, filtered, rectified and normalized. The processed EMG was mathematically broken into synergies and their activation ratio (from 100%). The higher number of synergies always reduces the residual error between the reconstructed EMG and the original EMG. The required number of synergies were defined as the minimum number of synergies that could reconstruct EMG signals with subtracting 5% error {(EMGoriginal -EMGreconstructed) = e, e/EMGoriginal CONCLUSIONS This study shows an increase in gait complexity by increase in number of synergies following a surgical alignment in ADS patients. More number of synergies postsurgery shows a more elaborate gait pattern since more number of synergies (modules) are required to rebuild the EMG signals, in addition to improvements in ability of the CNS in generating more number of independent or rich control signals. As an example, inability of poststroke patients in generating independent control signals for gait makes their CNS to activate numerous muscles with a single signal (at the same time), causing unwanted co-contractions that hinders their normal gait. We recommend that spine care providers use gait analysis as part of their clinical evaluation to provide an objective measure of function and to better understand the effects of the disease and its treatment on their patients’ gait, function, and, ultimately, quality of life. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The use of gait analysis in the assessment of patients afflicted with spinal disorders.

Use gait analysis to establish and detail the clinically relevant components of normal human gait, analyze the gait characteristics for those afflicted with spinal pathology, and identify those aspects of human gait that correlate with pre- and postoperative patient function and outcomes. Twenty patients with adult degenerative scoliosis (ADS), 20 patients with cervical spondylotic myelopathy (CSM), and 15 healthy volunteers performed over-ground gait trials with a comfortable self-selected speed using video cameras to measure patient motion, surface electromyography (EMG) to record muscle activity, and force plates to record ground reaction force (GRF). Gait distance and temporal parameters, ankle, knee, hip, pelvic, and trunk range of motion (ROM), duration of lower extremity EMG activity and peak vertical GRF were measured. Patients with ADS and CSM exhibited a significantly slower gait speed, decrease in step length, cadence, longer stride time, stance time, double support time, and an increase in step width compared to those in the control group. These patients also exhibited a significantly different ankle, knee, pelvic, and trunk ROM. Moreover, spinal disorder patients exhibited a significantly longer duration of rectus femoris, semitendinosus, tibialis anterior and medial gastrocnemius muscle activity along with an altered vertical GRF pattern. Gait analysis provides an objective measure of functional gait in healthy controls as well as those with ADS and CSM. This study established and detailed some of the important kinematic and kinetic variables of gait in patients with spinal disorders. We recommend that spine care providers use gait analysis as part of their clinical evaluation to provide an objective measure of function. These slides can be retrieved under Electronic Supplementary Material.

Vertebral fracture management

Osteoporosis-related acute vertebral fragility fracture is a debilitating condition that can cause significant morbidity in elderly patients. Appropriate treatment requires a multimodal approach by spine care providers. Initial management should be directed at achieving adequate pain control to facilitate early mobilization. In patients refractory to nonoperative treatment, vertebral augmentation may be utilized. Back extensor exercises, postural training, and active orthoses can help not only with symptom control but also reduce the progression of kyphosis. Appropriate treatment of osteoporosis should be initiated as soon as possible to minimize the risk of future fracture.

An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease.

OBJECTIVE Current costs associated with spine care are unsustainable. Productivity loss and time away from work for patients who were once gainfully employed contributes greatly to the financial burden experienced by individuals and, more broadly, society. Therefore, it is vital to identify the factors associated with return to work (RTW) after lumbar spine surgery. In this analysis, the authors used data from a national prospective outcomes registry to create a predictive model of patients' ability to RTW after undergoing lumbar spine surgery for degenerative spine disease. METHODS Data from 4694 patients who underwent elective spine surgery for degenerative lumbar disease, who had been employed preoperatively, and who had completed a 3-month follow-up evaluation, were entered into a prospective, multicenter registry. Patient-reported outcomes-Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (BP) and leg pain (LP), and EQ-5D scores-were recorded at baseline and at 3 months postoperatively. The time to RTW was defined as the period between operation and date of returning to work. A multivariable Cox proportional hazards regression model, including an array of preoperative factors, was fitted for RTW. The model performance was measured using the concordance index (c-index). RESULTS Eighty-two percent of patients (n = 3855) returned to work within 3 months postoperatively. The risk-adjusted predictors of a lower likelihood of RTW were being preoperatively employed but not working at the time of presentation, manual labor as an occupation, worker's compensation, liability insurance for disability, higher preoperative ODI score, higher preoperative NRS-BP score, and demographic factors such as female sex, African American race, history of diabetes, and higher American Society of Anesthesiologists score. The likelihood of a RTW within 3 months was higher in patients with higher education level than in those with less than high school-level education. The c-index of the model's performance was 0.71. CONCLUSIONS This study presents a novel predictive model for the probability of returning to work after lumbar spine surgery. Spine care providers can use this model to educate patients and encourage them in shared decision-making regarding the RTW outcome. This evidence-based decision support will result in better communication between patients and clinicians and improve postoperative recovery expectations, which will ultimately increase the likelihood of a positive RTW trajectory.

Understanding Competition in Spine Care.

The changing landscape from volume to value represents a natural transformation in the health care industry. Increasingly provider groups are finding themselves responding to unfamiliar market forces. Whether explicit or implicit, competition is playing a larger role for the sustainability of providers. For spine care providers who are attempting to navigate the transition from volume to value, understanding the forces that shape competition in health care can help achieve success.

Predictors of the efficacy of epidural steroid injections for structural lumbar degenerative pathology

BackgroundLumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not. PurposeWe set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI. Study DesignA prospective cohort study was carried out. Patient SampleA total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample. Outcome MeasuresBaseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded. MethodsA total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a “responder” (achieving MCID) or a “non-responder.” Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients. ResultsThere were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data. ConclusionWe have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI.

Pelvic incidence: an anatomic investigation of 880 cadaveric specimens.

Pelvic incidence is a position- and posture-independent parameter used to quantify sagittal balance of the spine, sacrum, pelvis and hips. Its functional consequences have been associated with a number of different pathologies of the spine. However, there exists considerable controversy over which demographic features contribute to the development of pelvic incidence. 880 cadaveric skeletons from the Hamann-Todd Osteological Collection were obtained. The innominate bones and sacrum were reconstructed, and pelvic incidence was measured using a previously validated technique. Specimens with obvious fracture, infection, or rheumatologic conditions were excluded from study. Descriptive data of age at the time of death, gender, race and height were collected. The average pelvic incidence was 46.0°±11.0°. Pelvic incidence did not change with age (r=0.026, p=0.288). There was no difference in pelvic incidence measurements between females and males (47.2°±13.8° vs. 45.8°±10.4°, respectively; p=0.257), although this analysis was under-powered. Pelvic incidence was higher in African-Americans compared to Caucasians (48.9°±11.0° vs. 44.9°±10.8°; p=0.001). There was no association between height and pelvic incidence (r=-0.042, p=0.164). This study represents the largest single cohort of pelvic incidence measurements reported in the literature. Our data suggest that pelvic incidence does not change with age or height, although racial differences do exist. As spine care providers increasingly rely on pelvic incidence as an important means to quantify sagittal balance, the normative data provided herein will provide an essential reference.

Background to Understanding Value-Based Surgical Spine Care

The Patient Protection and Affordable Care Act (PPACA) has rapidly shifted the focus of healthcare from volume to value (Quality/Cost). While much of the value-based reform movement has focused on transitioning incentives from quantity to quality of care, the escalating and unsustainable cost of healthcare has garnered even more attention. Hence, all stakeholders ranging from healthcare purchasers, employers, and third-party payers to hospital systems, physicians and patients alike are demanding more transparency in the relative value of their healthcare options. Understanding what works best for which patients at what costs in real world settings of care is now of highest priority. Spine pathology is among the most prevalent disease states worldwide. The annual cost of spine care as a whole is estimated at $100 billion in the U.S. alone.1 On a per-case basis, spine surgery is amongst the most costly procedures in U.S. healthcare.2 However, this needs to be balanced against the significant impairment and disability which can occur as a result of disorders of the spine and spinal cord. Now more than ever, the scientific measurement of health economic value is a critical component of effective reform for a sustainable, and more importantly, high quality healthcare system. As demonstrated in the manuscript by Resnick and colleagues, legislative and economic imperatives will mandate resource allocation be made only towards treatments with proven value. For the majority of spine treatments, their value remains undefined when compared to competing spinal treatments options as well as when compared to established therapies in other disease states. As a roadmap for spine care providers to fill this value evidence gap, Angevine and colleagues provided a detailed overview of currently accepted methods to measure the relative cost-effectiveness and cost-utility of competing treatment options. While these traditional patient-centered definitions of cost-effectiveness provide a quantitative measure of the relative value of one treatment versus another, the qualitative thresholds which determine what is cost-effective or high value are not well defined and may vary dramatically as a function of the decision-maker’s perspective. For example, the costs of treating oncologic conditions are high and yet typically do meet such qualitative thresholds. It is clear that cost effectiveness assessments need to be individualized according to the type of pathology treated.3 Nevertheless these well accepted methods provide a recognized metric for spine care providers and researchers to generate and interpret evidence on spine care value. Given the current evidence gap in spine care value, decision-analysis modeling is being increasingly utilized to estimate value when high level evidence does not exist. Edwards and colleagues describe the common methods of modeling cost-effectiveness by piecing together many complementary but separate studies with the “glue” of clinical assumptions. The authors appropriately highlight the equal importance of the validity of both economic and clinical assumptions that drive these models. Without active input from the spine clinician, both construction and analytical interpretation of decision-analysis models of cost-effectiveness cannot be reliably performed to help inform resource allocations. It is not enough for models of cost-effectiveness to adhere to sound statistical rules if they violate simple clinical face validity. As these models are being increasingly utilized to support payer-policy, spine clinicians must play an active role in critically examining their validity. The convergence of value measurement and clinical spine care delivery is a relatively new phenomenon that all spine care providers will have to increasingly navigate. Spine care providers and researchers are now at a crossroads, define the value of spine care, or have it defined for them. The perceived value of spine care treatments will define their place in tomorrow value-based healthcare system. The introductory papers in this Value focus issue provide a starting roadmap for such a path forward.

The role of decision analytic modeling in the health economic assessment of spinal intervention.

Narrative review. To review the common tenets, strengths, and weaknesses of decision modeling for health economic assessment and to review the use of decision modeling in the spine literature to date. For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers. This narrative review discusses the general components of decision analytic models, how decision analytic models are populated and the trade-offs entailed, makes recommendations for how users of spine intervention decision models might go about appraising the models, and presents an overview of published spine economic models. A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models. Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions. 4.

Cost-effectiveness, QALYs, and incremental cost-effectiveness ratios

The cost of healthcare in the United States has continued to grow at an unsustainable rate. Spine care has not been immune to these elevating costs. Given the current economic environment, policy makers and payers have started to consider a move towards a system of value-based healthcare. Spine care providers will be required to measure the value of the treatments that they provide. This manuscript discusses the concepts of value-based healthcare, outcomes measures, and cost-effectiveness and the influence they will have on our future practice.

United States Hospital Admissions for Lumbar Spinal Stenosis

Retrospective analysis of Nationwide Inpatient Sample and US Census data. To (1) document national trends in surgical hospitalizations with the primary diagnosis of lumbar spinal stenosis from 2000 through 2009; and (2) evaluate how those trends relate to race and ethnicity. In the United States, the rate of lumbar spinal stenosis surgery is increasing, and understanding how changing demographic trends impact hospitalization rates for this surgery is important. Multivariable regression models were used to determine associations between race and ethnicity and the rates of surgical hospitalization for lumbar spinal stenosis. All models were adjusted for age, sex, insurance, income status, geographical location, and comorbidities. From 2000 through 2009, the overall surgical hospitalization rate increased by 30%. Surgical hospitalization rates for lumbar spinal stenosis in the United States varied substantially across racial and ethnic groups. In 2009, white, non-Hispanics had the highest rate (1.074 per 1000) compared with black, non-Hispanics (0.558 per 1000; P< 0.001), and Hispanics (0.339 per 1000; P< 0.001). The relative differences persisted across time. There were substantial differences in rates of surgical hospitalization among individuals of different racial and ethnic groups. Possible causes were (1) differences in clinical decision making among spine care providers with regard to offering surgical care to minority populations; (2) differences in access to care because of financial, educational, or geographical barriers; and (3) differences in attitudes toward surgical care among those of different racial and ethnic groups. 3.

Defining the Value of Spine Care

The increased cost and frequency of spine-related procedures, expanding indications, and regional variation in care has led to a shift toward delivery of value-based spine care. In this model, payers show preference for interventions and treatments with proven value and incentivize providers who use such interventions and demonstrate value in their practices. Thus, spine care providers must understand how to determine the value of interventions and treatments. Determining value (ie, cost and quality of care, measured over time) can be challenging in the setting of spine care. Data collection and reporting are complicated by variation in diagnostic coding and surgical techniques. Typically, outcomes in spine care are based on subjective patient-reported measures that are influenced by concomitant orthopaedic, medical, and psychological disease. Health utility is a preferable measure of quality that can be converted into quality-adjusted life years and used in cost-effectiveness analysis. Although no standard currently exists, estimates of cost should include both direct and indirect costs of care over an adequate time horizon.

Defining the Value of Spine Care

The increased cost and frequency of spine-related procedures, expanding indications, and regional variation in care has led to a shift toward delivery of value-based spine care. In this model, payers show preference for interventions and treatments with proven value and incentivize providers who use such interventions and demonstrate value in their practices. Thus, spine care providers must understand how to determine the value of interventions and treatments. Determining value (ie, cost and quality of care, measured over time) can be challenging in the setting of spine care. Data collection and reporting are complicated by variation in diagnostic coding and surgical techniques. Typically, outcomes in spine care are based on subjective patient-reported measures that are influenced by concomitant orthopaedic, medical, and psychological disease. Health utility is a preferable measure of quality that can be converted into quality-adjusted life years and used in cost-effectiveness analysis. Although no standard currently exists, estimates of cost should include both direct and indirect costs of care over an adequate time horizon.

Spine Care Providers

Biomedical Safety & Standards 42(18):p 144, October 15, 2012. | DOI: 10.1097/01.BMSAS.0000421500.37914.6e