A Discussion: Neurosurgery and the Joint Commission offering of the Advanced Certification in Spine Surgery

How does an Advanced Certification in Spine Safety (ACSS) benefit spine patients?

Dr. Bisson (EB): The value of a national registry effort includes the ability for national benchmarking, the opportunity to monitor longitudinal patient outcomes, and it provides entry into national quality improvement programs with the ultimate goal of improving the value of care delivered to patients.

Dr. Steinmetz (MS): I agree with Dr. Bisson. The ultimate goal is to improve the quality and value of care delivered to your patients.

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There are four measures being captured in the American Spine Registry required for the Advanced Certification in Spine Surgery: Surgical site infection rates, new neurological deficits, unplanned return visit to the OR and pre-operative and post-operative patient reported outcomes.

How do these measures reflect important components of spine surgery for neurosurgeons?

EB: Important considerations for spine surgeons are providing optimal care for patients. Ideally, tailoring the treatment algorithm to individual patient-specific factors will lead to the best possible outcomes.

How do these reflect what a neurosurgeon considers in her or his spine practice?

EB: Three of the four core measures are intended to address specific adverse events following spine surgery. These complications are known to impact short term recovery. The fourth measure includes patient-reported outcomes (PROs), which can inform on functional recovery and quality of life.

MS: These measures are designed to reflect everyday practice and are known to impact outcome. Moreover, they may be mitigated. Further, they are collected nationally and permit benchmarking for practices and hospitals vs. other surgical groups.

All neurosurgeons work to reduce surgical site infections, which are often the issues that returns patients to the operating room for an additional surgery. Preventing complications, such as new neurologic deficits, and improved patient outcomes are the definition of quality care.

How does neurosurgery’s representation in ASR and ACSS measure development benefit neurosurgeons when it comes to the Joint Commission’s ACSS?

EB: The ASR’s Executive Board and both the Data Operations and Data Use Committees have equal representation from both neurosurgery and orthopedics. These individuals who understand the needs of the greater neurosurgical community were selected to define what variables are meaningful in understanding outcomes for our patients. These neurosurgeons also work in partnership with payors (insurance companies) as advocates for both patients and surgeons.

MS: The American Spine Registry is the only qualifying registry for submitting measured performance for the Joint Commission’s ACSS. Every hospital that wants that certification is going to have to participate in the ASR, which will help ensure the ASR becomes the most comprehensive collection of spine care data in the country. With neurosurgeon leaders having an equal part in leading the registry, neurosurgery is ensuring its place, driving scientific outcome insights and best practices of care for spine patients.

What are the benefits (efficiencies) of using ICD-10 codes to trigger inclusion in measure calculations?

EB: Using code-based triggers allows for more strict inclusion criteria. It will also enable us to compare procedures across specific diagnostic categories.

MS: Many registry efforts lack granularity. ICD-10 allows a more granular understanding of diagnoses and this permits a more precise comparison of procedures and pathologies.

Why are PROs so important to registries and outcome science?

EB: The goal for surgical spine patients is to improve function, decrease pain and disability and to improve quality of life. These goals can now be measured through validated PRO measures.

MS: In the past, outcome was largely determined by the surgeon and his or her biased opinion of how the patient was performing and/or reporting pain and disability.

PROs reflect patient perspectives on how they are able to function or how they are experiencing pain, often based on everyday activities. The scores are standardized and validated. This allows for true comparisons to be made on treatment effectiveness.

Why are they important to include in an advanced certification program?

EB: As previously stated, complications and/or adverse events are only a small piece of the overall clinical picture. A patient with one of these events may still have an overall excellent outcome, with improvement in function and ability to engage in his or her work and home life, which is the definition of a meaningful recovery.

For the PROs, can you comment on the value/importance of the 180-day range – (90 days prior, 90 days post-op) and how this this reflective of clinical practice?

EB: It is important to establish a baseline value to be able to demonstrate either improvement or worsening following intervention. With measures spanning 180 days and the intervention at 90 days, there is a wide enough range of time to assess the effectiveness of the intervention.

What is the advantage for neurosurgeons, now and in the future?

EB: For both patients and surgeons, the advantage of collecting both baseline and follow up PROs is to allow us to do comparative effectiveness and quality improvement studies. With large registry efforts, it also enables us to do predictive analytics, which increases our understanding of which patients are best suited for which surgeries.

When it comes to submitting required ACSS performance measures, are there advantages at both levels of participation?

MS: The four measures selected are central to clinical practice in spine surgery, making them accessible to all spine surgeons – regardless of hospital capacity for extensive follow up. This ensures all neurosurgeon participants can submit the measures required to qualify for advanced certification. The accreditation measures are oriented toward shorter-term outcomes reflecting efforts to ensure patient safety in the OR. It is important to build on this and I think the PROs measure, in particular, sets the stage for that potential. Longer-term follow up and continued patient-reported outcomes are a focus of vanguard participation in the ASR, which provides further benefits to participants.

What are some of the lessons neurosurgery learned from QOD Spine that were advantageous for ASR?

EB: The QOD effort is what enabled neurosurgery to take the next step and refine the strategy in data collection. Specifically, we as a specialty learned our strengths, including the ability to collect PROs longitudinally, and our weakness, which I believe is the ability to define unique diagnostic categories. We have built on these to include longitudinal PROs follow up and a more defined approach to collection of diagnostic and surgical information, which is code based.

Any final thoughts you’d like to share?

EB: The Joint Commission offering of the Advanced Certification in Spine Surgery was built by a collaborative effort between the ASR and the Joint Commission. It is the first joint venture between an accrediting body and a national registry effort and as such sets the stage for the development of future partnerships. These will allow for both neurosurgery and orthopedic spine leaders to have a voice as patient and surgeon advocates.