Value In Spine Surgery Research Articles

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state.

While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs. We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations. Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22. While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures. III.

Measuring Value in Elective Spine Surgery.

To summarize the main findings from research on measuring the value in spine surgery. Determining the value of surgical interventions, which is defined by the quality and efficacy of care received divided by the cost to deliver healthcare, is inherently complex. The two most fundamental components of value-quality and total cost-are multifactorial and difficult to quantify. A narrative review of all the relevant papers known to the author was conducted. It is straightforward to calculate the aggregate hospital cost following a surgical procedure, but it is not simple to estimate the total cost of a procedure-including the direct and indirect costs. These individual metrics can help providers make more educated decisions with regards to improving patient quality of life and minimizing unnecessary costs. A consensus of the appropriate cost-per-quality-adjusted life-year threshold of different spine surgeries needs to be established. As these metrics become more commonplace in spine surgery, the potential for personalized health care will continue to be developed. As the healthcare system shifts toward value-based care, there is a substantial need for research assessing the value as defined by the quality and efficacy of care received divided by the cost to deliver healthcare of specific spine surgery procedures. Studies on different predictors-both patient-specific and surgical-that may influence outcomes, cost, and value are required.

Achieving Value in Spine Surgery: 10 Major Cost Contributors.

Study Design:Narrative Review.Objectives:The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused—often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.Methods:We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal—if any—clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.Results:We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.Conclusions:In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

Prediction Models in Degenerative Spine Surgery: A Systematic Review.

Study Design:Systematic review.Objectives:To review the existing literature of prediction models in degenerative spinal surgery.Methods:Review of PubMed/Medline and Embase databases was conducted to identify articles between January 1, 2000 and March 1, 2020 that reported prediction model performance for outcomes following elective degenerative spine surgery.Results:Thirty-one articles were included. Twenty studies were of thoracolumbar, 5 were of cervical, and 6 included all spine patients. Five studies were externally validated. Prediction models were developed using machine learning (42%) and logistic regression (42%) as well as other techniques. Web-based calculators were included in 45% of published articles. Various outcomes were investigated, including complications, infection, length of stay, discharge disposition, reoperation, readmission, disability score, back pain, leg pain, return to work, and opioid dependence.Conclusions:Significant heterogeneity exists in methods used to develop prediction models of postoperative outcomes after degenerative spine surgery. Most internally validate their scores, but a few have been externally validated. Areas under the curve for most models range from 0.6 to 0.9. Techniques for development are becoming increasingly sophisticated with different machine learning tools. With further external validation, these models can be deployed online for patient, physician, and administrative use, and have the potential to optimize outcomes and maximize value in spine surgery.

Understanding Health Economics in Spine Surgery.

The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Enhanced recovery after spine surgery-a multinational survey assessing surgeons' perspectives.

Enhanced Recovery After Surgery (ERAS) is the object of numerous publications in various surgical fields. Still, its value in spine surgery is not as recognized as it is in other surgical domains. Our aim was to report neurosurgeons' opinions about ERAS in spine surgery. From December 2019 to January 2020, members of the European Association of Neurosurgical Societies were asked to complete an online questionnaire regarding ERAS in spine surgery. N = 234 participants responded to the survey (60% spine neurosurgeons; 22.6% working in private practice). Thirty-two percent reported to have more than 20years of experience, followed by surgeons having between 5 and 10 (27.4%), 10-15 (17.9%), 15-20 (12%), and 0-5years (10.7%). Gender distribution (12% vs 27% female gender, p = 0.04), private practice activity (28% vs 14%, p = 0.01), familiarity with the ERAS concept (57.4% vs 27%, p < 0.0001), and its implementation in the daily clinical practice (47.5% vs 18.3%, p < 0.0001) were statistically different between spine and general neurosurgeons. 54.7% of the surgeons were unfamiliar with ERAS in spine surgery. 63.7% considered ERAS as a progress; 36% declared to implement ERAS in their daily clinical practice. 1.7% reported ERAS as a decrease in the quality of management. 6.8% considered ERAS as not having an impact on patient care; 27.8% had no opinion. There were no differences in opinion on ERAS and its implementation between surgeons working in private and public hospitals. 69.5% of the spine surgeons considered ERAS having a positive impact on patient management, versus 55% of non-spine surgeons (p = 0.02). Efforts are necessary to promote minimal invasive pre-, intra-, and postoperative workflow to improve patient management and reduce complications or side effects particularly adapted to spinal surgery. Specificities of spine patients, in terms of chronic pain, pre- and postoperative pain management, and psychological issues have to be considered.

Creating value in spine surgery: using patient reported outcomes to compare the short-term impact of different orthopedic surgical procedures

BACKGROUND CONTEXTSociety increasingly asks Medicine to create “value” for patients. As health-care costs rise, this question will become more important. Debate exists regarding the relative “value” of many surgical procedures, including spinal surgery. Comparison of the relative value that patients experience after different orthopedic procedures is theoretical, but informs the ongoing debate. METHODSThe Patient Reported Outcome Measurement Information System (PROMIS) assessments for Physical Function, Pain Interference, and Depression are routinely collected in our orthopedic clinics. Patients who underwent lumbar discectomy (DSC) or arthroscopic anterior cruciate ligament reconstruction (ACLR) were retrospectively identified. Data relating to PROMIS domains, patient demographics, and other relevant encounter details were extracted. The primary outcomes were (1) preoperative PROMIS domain scores, (2) scores at a minimum of 40 days postoperatively for DSC patients and 133 days postoperatively for ACLR patients, and (3) the change in scores with surgery. Propensity score matching identified age-, sex-, race-, and comorbidity-matched groups from each cohort. Chi-square tests and nonparametric Kruskal-Wallis tests compared the distribution of outcomes and characteristics. Multivariate linear regression models with interactions between the matched cohort and operative phase estimated the change in the outcomes scores between the two cohorts and controlled for the baseline differences between them. RESULTSBefore surgery, the DSC cohort had lower physical function, higher pain interference and higher depression scores as compared with the ACLR cohort. This pattern remained postoperatively, indicating less desirable outcomes for DSC patients. However, after controlling for their baseline scores, DSC patients experienced significantly greater improvements after surgery of 3.84 (95% CI 1.08–6.60; p=.01), −4.87 (95% CI −7.52 to −2.23; p<.001), and −2.95 (95% CI −5.70 to −0.21; p=.04) points in their physical function, pain interference, and depression scores, respectively, as compared with ACLR patients. CONCLUSIONSBased upon PROMIS assessments at short-term follow-up, DSC patients receive a larger benefit from surgery than ACLR despite the overall less desirable postoperative PROMIS scores in the DSC cohort. This result, while theoretical, informs the debate regarding the comparative value of DSC to patients.

Value based spine care: Paying for outcomes, not volume

Spine pathology is among the most common, most disabling, and costliest disorders in the US health care system. Traditional reimbursement models in which volume of service rather than quality is incentivized has resulted in an unsustainable rise in cost. The focus for all stakeholders is now on value-based health care. Value is determined by the outcomes achieved per dollar spent to achieve those outcomes. Clinical registries and validated outcome tools are now making it possible for all spine practitioners to define and develop value-based care. Accurate measurement of outcomes and cost and identifying outliers are essential to improving the value in spine surgery.

Value in Single-level Lumbar Discectomy: Surgical Disposable Item Cost and Relationship to Patient-reported Outcomes.

This is a retrospective study. Compare improvements in health status measures (HSMs) and surgical costs to determine whether use of more costly items has any relationship to clinical outcome and value in lumbar disc surgery. Association between cost, outcomes, and value in spine surgery, including lumbar discectomy is poorly understood. Outcomes were calculated as difference in mean HSM scores between preoperative and postoperative timeframes. Prospective validated patient-reported HSMs studied were EuroQol quality of life index score (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire (PHQ-9). Surgical costs consisted of disposable items and implants used in operating room. We retrospectively identified all adult patients at Cleveland Clinic main campus between October 2009 and August 2013 who underwent lumbar discectomy (652) using administrative billing data, Current Procedural Terminology (CPT) code 63030. HSMs were obtained from Cleveland Clinic Knowledge Program Data Registry. In total, 67% of operations performed in the outpatient or ambulatory setting, 33% in the inpatient setting. Among 9 surgeons who performed >10 lumbar discectomies, there were 72.4 operations per surgeon, on average. Mean surgical costs of each surgeon differed (P<0.0001). In a multivariable regression, only the surgeon and surgery type (outpatient or inpatient) were statistically correlated with surgical costs (P<0.0001 and 0.046, respectively). Changes in EQ-5D, PDQ, and PHQ-9 were not correlated with surgical costs (P=0.76, 0.07, 0.76, respectively). In multivariable regression, only surgical cost was significantly correlated to mean difference in PDQ (P=0.030). More costly surgeries resulted in worse PDQ outcomes. Mean surgical costs varied statistically among 9 surgeons; costs were not shown to be positively correlated with patient outcomes. Performing an operation using more costly disposable supplies/implants does not seem to improve patient outcomes and should be considered when constructing preference cards and during an operation.

Outcomes and Value in Spine Surgery

Health care costs are on an unsustainable upward trajectory and spine disorders are one of the most costly disease states worldwide. Value-based care is being implemented across all medical specialties. However, the true meaning of value and how to accurately and precisely measure value poses a significant challenge. The keys to identifying and optimizing value in spine care lies at the individual patient level. Analyzing drivers of cost from all perspectives and identifying patient factors, surgeon factors, and others that lead to increased cost and cost variation is critical to make improvements in value. Equally important, is the ability to accurately measure patient outcomes. Innovative methods are being developed for measuring patient outcomes and developing evidence to guide clinical decision-making. It can no longer be acceptable to only look at population based outcomes when evaluating the value of a spine intervention, rather the factors that drive variation in outcomes in the outliers must be identified and modified. Understanding what drives cost in spine surgery, the ability to accurately measure outcomes following spine intervention, and identifying factors that drive variation in cost and outcomes is critical to improving the value of health care. These concepts are essential in order to strive toward individualized care, which will not only lead to improved benefit to the patient, but also benefit to the surgeon, the hospital, the payer, and society as a whole.

Bending the Cost Curve-Establishing Value in Spine Surgery.

As publically promoted by all stakeholders in health care reform, prospective outcomes registry platforms lie at the center of all current evidence-driven value-based models. To demonstrate the variability in outcomes and cost at population level and individual patient level for patients undergoing spine surgery for degenerative diseases. Retrospective analysis of prospective longitudinal spine registry data was conducted. Baseline and postoperative 1-year patient-reported outcomes were recorded. Previously published minimal clinically important difference for Oswestry Disability Index (14.9) was used. Back-related resource utilization and quality-adjusted life years (QALYs) were assessed. Variations in outcomes and cost were analyzed at population level and at the individual patient level. A total of 1454 patients were analyzed. There was significant improvement in patient-reported outcomes at postoperative 1 year ( P < .0001). For patients demonstrating health benefit at population level, 12.5%, n = 182 of patients experienced no gain from surgery and 38%, n = 554 failed to achieve minimal clinically important difference. Mean 1-year QALY-gained was 0.29; 18% of patients failed to report gain in QALY. For patients with 2-year follow-up, surgery resulted in 0.62 QALY-gained at average direct cost of $28 953. A wide variation in both QALY-gained and cost was observed. Spine treatments that on average are cost-effective may have wide variability in value at the individual patient level. The variability demonstrated here represents an opportunity, through registries, to identify specific care that may be less effective, and refine patient-specific care delivery and indications to drive overall group-level treatment value. Understanding value of spine care at an individualized as well as population level will allow clinicians, and eventually payers, to better target resources for improving care for nonresponders, ultimately driving up the average health for the whole population.

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Understanding Value in Spine Surgery

Mr. Patel is a Medical Student, Drexel University College of Medicine, and Dr. Rihn is Associate Professor, Department of Orthopaedic Surgery, Thomas Jefferson Hospital, and the Rothman Institute, 925 Chestnut St, 5th Floor, Philadelphia, PA 19101; E-mail: [email protected]. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations related to this CME activity. Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on March 31, 2015.

The effect of dexmedetomidine infusion on propofol requirement for maintenance of optimum depth of anaesthesia during elective spine surgery

Background:Maintenance of adequate depth of anaesthesia in spine surgery is vital to prevent awareness, to reduce stress response and possible autonomic instability frequently associated with spine surgery. Dexmedetomidine, a α2-adrenoceptor agonist with analgesic and sedative adjuvant property has been found to reduce dose requirement of multiple anaesthetic agents both for induction and during the maintenance of anaesthesia.Aim:The aim of this study is to observe the effect of dexmedetomidine, on the requirement of propofol for induction and maintenance of adequate depth of anaesthesia during spine surgery.Methods:It was a prospective, randomised, double-blinded, parallel group, placebo controlled and open-lebel study in tertiary care hospital. A total of 70 patients aged 20-60 years, American Society of Anaesthesiologists GradeI and II, scheduled for elective spine surgery were randomly allocated into two groups. Each patient of Group D (n=35) received an initial loading dose of dexmedetomidine at 1 μg/kg over 10 min, started 15 min before induction of anaesthesia followed by an infusion at a rate of 0.2 μg/kg/h. Patients of Group P (n=35) received the same volume of 0.9% normal saline solution as placebo. Requirement of propofol at induction and during maintenance was calculated maintaining bispectral index between 40 and 60. P<0.05 was considered to be statistically significant.Results:Mean requirement of propofol was found to be lessened by 48.08% and 61.87% for induction and maintenance of anaesthesia respectively while using dexmedetomidine.Conclusion:Administration of dexmedetomidine significantly reduces the requirement of propofol while maintaining desired depth of anaesthesia without any significant complication.

Defining the Value of Spine Care to Society

Defining value in spine surgery increasingly considers the patient's perspective, a task that requires quantifying outcomes using validated, patient-derived outcome instruments. Both general and disease-specific instruments have been used to measure outcomes after spinal surgery. Some outcomes instruments can be used to derive a utility score, a metric that grades patient health along a continuous spectrum from 0 to 1. The change in utility score after a procedure and the procedure cost are used to determine the cost per change in utility, a measurement that forms the basis of cost-effectiveness analysis and can be compared between procedures.