AANS Neurosurgeon | Volume 27, Number 2, 2018

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An Infrastructure for Analyzing and Reporting

The NeuroPoint Alliance (NPA) Quality Outcomes Database (QOD) serves as a national clinical registry for the most common neurosurgical, neurovascular and spine procedures. It provides individual surgeons, practice groups, hospitals and healthcare systems with an immediate infrastructure for analyzing and reporting the quality of their care. The QOD collects clinical variables that allows appropriate risk-adjustment, patient-reported outcomes and longitudinal follow-up to determine the sustainability of treatment effects across modules on lumbar spine, cervical spine, deformity and neurovascular care. 

The QOD Lumbar Spine registry launched in March 2012 with the aim to assess the extent to which lumbar spinal surgery improves pain, disability and quality of life. The registry tracks all lumbar and thoracic surgical cases for patients with degenerative disease, including disc herniation, spondylolisthesis, stenosis, adjacent segment disease and pseudoarthrosis. The registry determines risk-adjusted benchmarks of surgical morbidity and comparative effectiveness of lower-back treatments. Data derived from the QOD were referenced during several scientific sessions the at the 2018 AANS Annual Scientific Meeting in New Orleans. 

 

Elderly Patients have Worse EQ-5D Outcomes after Spondylolisthesis Surgery than Young Patients, yet they are Satisfied with Surgery

Presented at the 2018 AANS Annual Scientific Meeting by Anthony DiGiorgio, DO, MPH

Since the publication of the Spinal Laminectomy vs. Instrumented Pedicle Screw (SLIP) Trial and Swedish Spinal Stenosis Study, there has been renewed interest in defining the populations that fare best following spondylolisthesis surgery. Interestingly, both of the aforementioned studies did not include patients that were older than 80 years of age. With the aging population, octogenarians are receiving more spinal surgery. Thus, it is critical to define how this patient population fares after spondylolisthesis surgery. Utilizing a high quality, prospective and audited spondylolisthesis dataset, we can help to better understand how this population fares after surgery.

We found that, though elderly patients had inferior overall quality of life at one year, they achieved similar satisfaction with surgery. Furthermore, they did not have inferior outcomes with back pain, leg pain and disease-specific disability. Just as with the younger cohort, elderly patients improved significantly from baseline at one year for all patient-reported outcome metrics. Therefore, surgery should still be considered for well-selected elderly patients that have failed conservative management of lumbar spondylolisthesis.

A retrospective analysis of QOD data has been conducted. QOD is a prospective registry that includes patient-reported outcomes collected at designated intervals. A total of 808 patients underwent surgery for grade 1 degenerative lumbar spondylolisthesis at twelve high-enrolling sites. Elderly patients were identified as more than 80 years of age. Baseline and surgical variables were collected. Numeric rating scale (NRS) back pain, NRS leg pain, Oswestry Disability Index (ODI), EuroQoL-5D (EQ-5D) and the North American Spine Society (NASS) Satisfaction Questionnaire data were collected at baseline, three months and 12 months.

The study results indicate that 36 patients (4.5 percent) were elderly with a range of 80-95 years. Elderly patients had lower mean BMI (28.1±4.9 vs. 30.7±6.4, p=0.01), a higher proportion of osteoporosis (16.7 vs. 6.5 percent, p=0.04) and were less independently ambulatory at baseline (75.0 vs. 88.0 percent, p=0.04). Elderly patients received fewer fusion procedures (41.7 vs. 75.8 percent, p<0.001). There was no difference in satisfaction at 12 months (elderly 83.3 vs. 83.7 percent NASS 1/2; p=0.85) as well as three-month readmission (elderly 8.3 vs. 3.2 percent, p=0.24) and 12-month reoperation rates (elderly 8.3 vs. 4.9 percent, p=0.60). At baseline, the elderly cohort had less NRS back pain (5.6±3.1 vs. 6.9±2.6, p=0.02) and higher EQ-5D (0.62±0.19 vs. 0.54±0.24, p=0.04). At 12 months, both the elderly and the control cohort improved significantly with respect to mean baseline values for NRS back and leg pain, ODI and EQ-5D (p<0.01 for all comparisons). In multivariate analysis, elderly status predicted inferior 12-month EQ-5D change scores (OR 0.92, 95 percent CI 0.86-0.99, p=0.03), but was not predictive of NRS back and leg pain and ODI change scores (all p<0.05). In adjusted analysis, age <80 years was associated with inferior improvements in EQ-5D at 12 months following lumbar spondylolisthesis surgery.

The presenters wish to acknowledge those who made the spondylolisthesis project dataset possible, including Spondy Study Principle Investigators Erica Bisson, MD, MPH, FAANS; Mohamad Bydon, MD, QOD Vice-Director; and NPA Board members Praveen Mummaneni, MD, FAANS, and Jack Knightly, MD, FAANS. Without their commitment and tireless efforts, there would not be this carefully curated, high-quality data with which to work.

Contributors include Andrew K. Chan, MD; Erica Bisson, MD, MPH, FAANS; Mohamad Bydon, MD; Kevin Foley, MD, FAANS; Eric Potts, MD, FAANS; Christopher Shaffrey, MD, FAANS; Mark Shaffrey, MD, FAANS; Anthony Asher, MD, FAANS; Michael Wang, MD, FAANS; John Knightly, MD, FAANS; Jonathan Slotkin, MD, FAANS; and Praveen Mummaneni, MD, FAANS.


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The Institute for Healthcare Improvement – NeuroPoint Alliance Cooperative Quality Improvement Project: Using National Registries to Design Continuous Quality Improvement Protocols
Presented at the 2018 AANS Annual Scientific Meeting by Scott Zuckerman, MD

NPA’s long-standing Quality Outcomes Database (QOD) program is specifically designed with quality outcome improvement in mind. In 2017, NPA laid the groundwork for national-level improvement work through a nine-month cooperative project that is made possible through a generous grant from the Neurosurgery Research and Education Foundation (NREF). The NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) project is designed as a novel attempt to develop quality improvement (QI) tools from registry data that improve the quality of care delivered to patients. To date, no group has combined insights from a national registry with validated QI methods.

An examination of QOD data revealed patient- and site-level variation in several areas, including unplanned hospital readmissions and length of stay. These two areas serve as logical targets for improvement because length of stay can serve as one marker of readmission risk. Reducing readmission and length of stay after elective lumbar fusion are the chosen areas for the pilot module.

The NPA-IHI program prospectively enrolled patients undergoing 1-3 level lumbar fusion across eight institutions. Commencing with the research phase, literature review and stakeholder interviews were conducted, followed by QOD analysis to identify the key drivers of readmission and length of stay. In the subsequent intervention phase, specific interventions addressed the previously identified drivers. In the final measurement phase, the application of these interventions and overall patient experiences were measured and reported. The participating institutions shared their observations, experiences, locally developed planning tools and cross-functional team approaches to making measureable and sustainable improvements.

A total of 232 patients were included with an average LOS of 3.4±1.8 days for one-level fusion (N=143) and 4.4±2.4 days for two-level fusion (N=89). In the research phase pain control and medical comorbidities emerged as key drivers of both outcomes. Eighty percent of readmissions occurred within the first four weeks and 46 percent within 14 days. For the intervention phase, the Rounding Tool checklist was developed with nine care parameters and utilized daily at bedside. The measurement phase was the successful application of the Rounding Tool. The top three reasons preventing discharge were mobility status (64 percent), indwelling devices (51 percent) and pain control (38 percent). Preliminary data shows the majority of patients reported a positive overall experience.

The project is a novel method for combining insights gained from a national registry with continuous quality improvement protocols in a multi-institutional setting. Future efforts will be focused on pre-operative, hospital and post-discharge interventions and using the registry platform itself as a method of gathering process data at the point of service.

The presenters wish to acknowledge the eight institutions that participated in this structured quality program under the direction of the NPA physician leadership team of Anthony Asher, MD, FAANS, (QOD Director) and Mohamad Bydon, MD, (QOD Vice-Director).

  • Atlantic Neurosurgical Specialists
  • Carolinas Neurosurgery and Spine Associates
  • Goodman Campbell Brain and Spine
  • Norton Leatherman Spine Center at the University of Louisville
  • Semmes Murphey Clinic
  • The University of California at San Francisco
  • The University of Utah
  • Vanderbilt University Medical Center

Contributors are Vincent J. Rossi, MD; Anthony Asher, MD, FAANS; Clinton Devin, MD; Scott Zuckerman, MD; Kevin Foley, MD, FAANS; Jack Knightly, MD, FAANS; Erica Bisson, MD, MPH, FAANS; and Steven Glassman, MD.

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