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AANS Neurosurgeon | Volume 28, Number 3, 2019

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Neurosurgical Value in Health-care Reform, Reconciling Quality and Safety

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Health care in the U.S. has witnessed a tremendous change in organization over the last few decades. In the past, a majority of physicians and surgeons treated patients in private practice, individually developing best therapies and approaches. Today, most physicians practice in large medical centers, delivering care that is studied, critiqued and vetted for quality on the institutional scale. Parallel to these changes, reimbursement has evolved from a fee-for-service model to a bundled, value-based model. Accessibility, affordability and accountability are the new charge.

Value Based Health-care Provisions
“Value” is a term that has gained increasing popularity among policy makers, health-care administrators and the public at large. Generally speaking, value-based care refers to maximizing care quality for patients while minimizing cost. Under the Patient Protection and Affordable Care Act (PPACA), rising health-care costs are being controlled with bundled payments and pay-for-performance measures. To date, most efforts to impact quality have focused on performance measures, outcomes and patient safety. Patient safety is a key goal of the PPACA and was assessed as a system-based parameter in the 1999 Institute of Medicine report, To Err is Human.

Under new health-care provisions, quality is being promoted in hospitals using several different metrics. As new policies are implemented on the ground level, literature is scarce on how these metrics interact with the practice of neurosurgery. Neurosurgical patients are unique, as they are often critically ill, and daily decisions often directly affect their long-term quality of life. Though many metrics may mean well, in practice, they may not be the best tools for delivering safe care. In neurosurgery, quality may be at odds with safety.

The Difficulty of Using Quality Metrics for Neurosurgical Patients
Re-admission is an example of such a quality metric. Low 30-day re-admission rates have often been equated with quality of care. Under the PPACA, this metric is being utilized by hospitals and payors to improve quality, with the implementation of reimbursement penalties for early re-admissions. Using such a metric is difficult with neurosurgical patients. These patients can deteriorate quickly with minimal warning signs, and the expertise required for their care typically means they must visit major academic medical centers, of which there may be few in one area.

In such cases, re-admission may actually reflect safe and quality patient care rather than the reverse. In a retrospective analysis of 348 patients treated at Barnes Jewish Hospital by attending neurosurgeons at Washington University in St. Louis, 28 percent (115/407) of identified re-admissions were due to complications in spite of best practices or complications due to the natural progression of disease. Other research teams have confirmed a high rate of re-admission among neurosurgical patients, often as a result of post-surgical complications. It is important to note that although readmission was correlated with shorter survival after surgery, it also disproportionately affected sicker patients who required post-acute care after their surgical admission.

One motive for physicians to discharge patients as early as possible after surgery is to avoid post-surgical complications and hospital acquired conditions. Hospital acquired conditions are another metric that may be inappropriately applied to neurosurgical patients. Prevention of post-operative urinary tract infections (UTIs) are a frequent target of quality improvement. However, due to immobility as a result of surgery or their underlying disease, as well as neurogenic bladder issues, such a metric may be unsuitable for neurosurgical patients. Many UTIs may be unavoidable in select severely compromised stroke, spinal cord injury or brain injury patients. In fact, UTIs are frequently associated with other post-surgical complications, which may not always be avoidable in the most infirm neurosurgical patients. Post-operative venous thromboembolism (VTE) is another hospital acquired condition being measured as a surrogate for quality. However, there is evidence to suggest that the risk of a post-operative VTE may be high enough in some neurosurgical patients that it may not be a completely avoidable complication.

With the current health-delivery system so focused on process and avoidance of complications and re-admissions, there may be unintended consequences for neurosurgeons and their patients. Hospitals may discourage surgeons from admitting and operating on patients with high risk of complications. This trend may increase further as hospitals enter more value-based, risk-sharing arrangements with insurers.

Appropriate risk adjustment and stratification of patients must be insured in order to guarantee appropriate access and high-quality care for neurosurgical patients who need care the most. The University HealthSystem Consortium (UHC), an alliance of many of the nation’s academic medical centers, has developed quality and safety metrics for its members that are based on a patient’s severity of illness. These tools allow hospitals to compare their performance results to national benchmarks. The Centers for Medicare and Medicaid (CMS) also takes into account both severity of illness (SOI) and case mix index (CMI) to adjust hospital payments based on patient comorbidities. These SOI and CMI metrics require appropriate documentation by physicians, a frequent area of focus for hospital coders, and has become a regular aspect of education for neurosurgical trainees.

Quality and Safety are the Ultimate Goals
Furthermore, future research is needed to validate these metrics as appropriately identifying high-risk neurosurgical patients. The bottom line is that quality and safety are undeniably goals to which physicians and surgeons should aspire. Health care is becoming more accountable and adverse outcomes should be minimized. However, through well-intentioned but ultimately inappropriate quality metrics imposed by hospitals, neurosurgeons may be distracted from the most important factor — the individual patient.

The value of neurosurgery comes from the high-quality care we deliver to every patient. Health-care policies at the national and hospital levels should reflect the uniqueness of every patient through appropriate risk stratification. Protocols that identify early patients with high risk of complications should be developed and validated. Documentation should reflect the clinically relevant issues pertinent to patient care and not be used for billing purposes. Future bundled payment initiatives should take into account the challenges of an individual patient’s unique medical background to ensure future access for all patients. With these changes, patient safety can become a primary goal, and quality becomes its natural derivative.

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