“What are the chances I will recover?” It’s the question every patient asks, every managed care company gambles with and every physician needs to answer. How do you monitor a patient’s outcome for a certain condition following a specific procedure? For better or worse, outcomes studies are one of the “hottest” topics in medicine and are popping up nationwide.
To address outcomes, guidelines, standards and quality issues within neurosurgery, The American Association of Neurological Surgeons and Congress of Neurological Surgeons created the Committee on Assessment of Quality, chaired by Robert Florin, MD. The Outcomes Committee, chaired by Robert E. Harbaugh, MD, falls under the direction of the Committee on Assessment of Quality (CAQ) and is dedicated to producing outcomes instruments for neurosurgeons to use within their own practices.
“The basic function of the CAQ is to measure or assess how well a component of quality approaches some standard of reference in healthcare delivery, ” Dr. Florin said. “The ability to actually measure quality, defined as the degree of conformance to a standard, requires that such a standard exist and be available for comparison to the component of quality under examination. Assessment of quality becomes a tool to evaluate how well an intervention approaches such a standard, and translates into a judgment of how well the intervention worked considering the benefits, risks and costs.”
Background on the AANS/CNS Outcomes Committee
Outcomes studies started to appear during the 1980s as third party payers and patients began to question why there were such variations in health services delivery in different parts of the country, or even from physician to physician in the same city. Outcomes studies set out to improve the health of a patient or community in the most cost-efficient manner by analyzing the way care was delivered, the clinical standard for a specific condition, patient satisfaction and the overall cost of the patient care.
“Outcomes studies are a controversial issue in medicine,” Dr. Florin said. “But, other organizations, like third party payers, are conducting these studies on their own and drawing conclusions from their data. If we feel it is appropriate to question these studies, we must have data of our own to counter with.”
The AANS/CNS Outcomes Committee consists of representatives from each of the Joint Sections and various consultants. The committee has created two outcomes measurement instruments and has slated other projects for 1998. Most of the projects use NEUROSURGERY://ON-CALL® as the data submission point.
The goals of the Outcomes Committee are:
- To serve as a resource for information regarding outcomes studies
- To educate the neurosurgical community regarding the value and methodology of outcomes studies
- To supply generic and disease-specific outcomes reporting instruments to neurosurgeons interested in this work
- To conduct national outcomes research in a cost-effective manner
- To develop a data management mechanism for neurosurgery that could be used at a national level with minimum expense.
“One problem with many outcomes studies is that they are being conducted by people who know little or nothing about the disease process being evaluated,” Dr. Harbaugh said. “This is why it is critical that professional organizations, like the AANS and CNS, be involved in neurosurgical outcomes studies. We are clearly the ones who have the best understanding of the conditions, the procedures, the patients and how different variables can affect outcome.”
Third-party payers, healthcare organizations and other groups have been conducting outcomes studies that affect neurosurgical procedures for at least the past 5 years.
“Our membership should be aware of the possibility that their practice behavior resulting from the applications of various monitoring methods is being assessed,” J. Charles Rich, MD, said as President of the AANS in 1996. “They should also become better informed as to how that evaluation occurs and for what purposes. In one way or another, it is going on all around us.”
Physiatrists, orthopedic surgeons and neurological surgeons, for instance, sometimes differ in their approach to the diagnosis and treatment of cervical and lumbar radiculopathic syndromes.
“Because a given Health Plan Physician Board is likely to increasingly employ the reasonable criteria of value = quality of outcome divided by cost, in deciding about referral patterns, who will end up providing an accurate definition for the numerator on the right side of that equation and to whose advantage that definition derives becomes very important,” Dr. Rich said. “Like it or not, this is an area we need pay close attention to.”
Aneurysm and Carotid Endarterectomy Local Outcomes Database
Currently, members can download aneurysm and carotid artery disease outcomes measurement instruments from NEUROSURGERY://ON-CALL®. These instruments allow neurosurgeons to keep a local database of aneurysm and carotid patients from their own practice. Information is not submitted to a national database.
“These are the first steps and the most basic of outcomes studies,” Dr. Harbaugh said. “It helps document patient risk factors, location and size of aneurysms, and patient outcome. It allows a neurosurgeon to present data on how many cases he or she treats and the patient outcomes.”
Once national data has been compiled for a specific condition, physicians can use local databases to see how they compare on length of stay, complications, patient satisfaction, and other factors.
“These are meant for self-assessment,” Dr. Harbaugh said. “By including risk factors and patient information, it makes the studies more credible. Obviously, a neurosurgeon who treats high risk patients would be expected to have less favorable outcomes.”
Aneurysm Outcomes Pilot Study
The Outcomes Committee has arranged for an national intracranial aneurysm outcomes study to begin in January of 1998. The study includes 11 centers from around the United States and will measure clinical, lesional and functional outcomes in patients treated with microsurgery or neuroendovascular procedures.
“This is a pilot study for us,” Dr. Harbaugh said. “We want to test out the submission process and data analysis to see what our capabilities are. We need to actually start collecting data to see where the problems lie. We are hoping to make this is a very meticulous study.”
The study will analyze patient risk factors; aneurysm risk factors, such as size and location; length of hospital stay; complication rates; quality of life/functional health status measures; and patient satisfaction. The SF-36 form, which tests the patients perception of quality of life, will be used to measure functional outcome. The GHAA 9 will be used to measure patient satisfaction.
The neurosurgery centers involved in the study include both academic and private practice groups Patients will be enrolled over a six month period and followed for an additional six months. It is anticipated that about 300 patients will be involved in the study.
“We don’t expect every neurosurgeon to be interested in keeping such a detailed database on all patients,” Dr. Harbaugh said. “Our goal is to develop basic, generic instruments such as a neurosurgical ‘report card’ that can easily be used to help in negotiating with third party payers, and also to develop more complex, disease specific instruments that will permit meticulous neurosurgical outcomes research to be done on a national basis.”
The Future of Outcomes Studies
Neurosurgeons have already presented scientific abstracts and articles showing how an outcome study, clinical pathway or guideline has improved patient care or reduced cost.
“Reliable outcomes studies can lead to meaningful practice guidelines and clinical pathways which subsequently lead to improved outcomes,” Dr. Harbaugh said. “They are all tied together with the goal of providing efficient, effective patient care based on reliable data. At present we are pursuing a system that will allow national outcomes studies to be done via the NEUROSURGERY://ON-CALL® Web site. Eventually such a system can be used for self-assessment and perhaps for re-accreditation.”
In a poster presented at the 1996 CNS Annual Meeting, physicians KL Saban and Michael J Caron concluded that “implementation of a clinical pathway for lumbar microdiscectomy decreased average length of stay without significant changes in patient outcome or satisfaction.” The poster showed morbidity, mortality, readmission rate, length of stay and patient satisfaction before and after a clinical pathway was implemented and showed a 24 percent decrease in LOS after the pathway took effect.
The Guidelines for the Management of Severe Head Injury were developed by the AANS and Joint Section on Neurotrauma and Critical Care in 1995. These are the only national practice guidelines relating to neurosurgery that have been released. According to a recent Trauma Section survey, 93 percent of neurosurgeons polled were familiar with the Guidelines. Over 45 percent of those polled said the Guidelines have changed their practice.
“The results of the survey show that it appears the Guidelines have had significant impact on the care of severe head injury patients in North America,” Donald Marion, MD, one of the authors of the Guidelines, said. “Clearly, however, neurosurgeons also treat patients in ways that they feel are most appropriate, irrespective to the Guidelines.”
There are several other practice guidelines currently under development by the Sections, including severe head injury in children, mild head injury, spinal cord injury, and gliomas.
“No matter if it’s outcomes studies, guidelines or some other tool, our overall goal is the same,” Dr. Florin said. “We must create and bring a standard of quality to the healthcare field.”