The National Neurosurgery Quality & Outcomes Database (N2QOD), recently rebranded as the Quality Outcomes Database (QOD), is one of the NeuroPoint Alliance’s (NPA) major initiatives. QOD, a national prospective clinical registry for surgical procedures and practice patterns, tracks the quality of surgical care for common cranial and spinal neurosurgical procedures and provides practices and hospitals with an immediate infrastructure for analyzing and reporting the quality of their care. Through the NPA, actively participating academic and private-practice surgeons have the opportunity to become involved in a number of clinical outcomes research projects involving the scientific analyses of the QOD aggregate dataset. The following QOD presentations were delivered at the 2016 AANS Annual Scientific Meeting:
Predictive Model for Return to Work after Elective Surgery for Lumbar Degenerative Disease: An Analysis from National Neurosurgery Quality Outcomes Database Registry (QOD)
Presenting Author: Silky Chotai, MD
Author Block: Matthew J. McGirt, MD, FAANS; Clinton Devin, MD; Mohamad Bydon, MD; Kristin Archer, DPT, PhD; Kevin T. Foley, MD, FAANS; Meic H. Schmidt, MD, MBA, FAANS; Steven Glassman, MD; Jack Knightly, MD, FAANS; Anthony L. Asher, MD, FAANS; N2QOD Investigator group
Current costs associated with spine care are unsustainable. The productivity loss and time away from work in gainfully employed patients contributes greatly to the financial burden. Therefore, it is vital to identify the factors associated with returning to work after lumbar spine surgery. The investigators presented a predictive model of the ability to return to work after lumbar spine surgery for degenerative disease. Patients undergoing spine surgery for degenerative lumbar disease were entered into the prospective multi-center registry, (N2)QOD Lumbar Spine. Patients that were employed preoperatively and who completed three-month follow-up were included in the analysis. The time to return to work is defined as the period between operation time and the date of returning to work. A multivariate Cox proportional hazards regression model, including an array of preoperative factors, was fitted for return to work.
The investigators identified the predictors of returning to work after lumbar spine surgery. Early identification and discussion with patients regarding the probability of return to work, based on these predictors, has the potential in promoting patient, payors and employers to have realistic expectations for returning to work after surgery resulting in improved patient satisfaction and potential health care savings.
The presenting author provided the following additional comments:
We present a novel risk-adjusted predictive model for return to work (RTW) which provides significant value as a starting point for patient-level predictive analytics to guide shared decision-making with the goal of optimizing outcomes at the individual patient and population levels. By enabling patient-specific probabilistic counseling at the point of care, we seek to facilitate the involvement of all stakeholders in true shared decision-making which can help set appropriate expectations prior to surgery (with the potential to improve patient satisfaction), modify factors that could help improve the potential for RTW and possibly reduce health-care expenditures in situations in which surgical care is deemed unlikely to achieve satisfactory outcomes.
Silky Chotai, MD
Impact of Functional Status of Patient on Satisfaction with Surgery 12 Months after Elective Spine Surgery for Lumbar Degenerative Disease
Presenting Author: Silky Chotai, MD
Author Block: Matthew J. McGirt, MD, FAANS; Clinton Devin, MD; Mohamad Bydon, MD; Kristin Archer, DPT, PhD; Kevin T. Foley, MD, FAANS; Meic H. Schmidt, MD, MBA, FAANS; Steven Glassman, MD; Jack Knightly, MD, FAANS; Anthony L. Asher, MD, FAANS; N2QOD Investigator group
In this era of value-based reforms, the quality of care is measured by patient reported outcomes (PROs) and patients’ perception of overall care. The impact of baseline and 12-month Oswestry disability index (ODI) on satisfaction with surgery is not well documented. In this analysis, the investigators determined the impact of functional status of the patient on satisfaction with surgery. Patients undergoing spine surgery for degenerative lumbar disease were entered into the prospective multi-center registry, (N2)QOD. Baseline and 12-month follow-up ODI was recorded. Satisfaction was measured using the North American Spine Society (NASS) satisfaction questionnaire. Previously published values of minimal clinically important differences (MCID) for ODI:14.9 was used. Univariate and multivariate analyses were conducted to determine the impact of baseline and 12-month ODI on patient satisfaction.
Functional status of the patient at 12-months following surgery had a significant impact on satisfaction. Patients with higher baseline ODI achieved higher change scores; however, they were not as satisfied. Satisfaction should not be used as a sole yardstick to measure outcomes and quality of care after spine surgery. Clinically significant functional outcomes, including 12-month ODI scores and change scores, should be utilized to report and promote the quality of spine care.
The presenting author provided the following additional comments:
Patients’ satisfaction with outcome is an important component of health-care quality. The improvement after surgery does not always correlate with satisfaction with outcome. In this study, we demonstrate that patients’ disability status (ODI score) at 12-months following surgery had significant impact on satisfaction with outcome. On the other hand, patients who sustain significant improvement from surgery, as measured by the change in ODI score and functional status of patient, do not achieve satisfaction with outcome to meet their expectations. Therefore, satisfaction with outcome should not be used as a sole quality metric. Satisfaction may be utilized in conjunction with ODI score at baseline and 12-months, as well as safety of care, to provide an assessment of the quality of spine surgery provided.
Silky Chotai, MD
Risk Factors for 30-day Re-operation and 90-day Readmission: Analysis from the National Neurosurgery Quality and Outcomes Database (QOD) Lumbar Spine Registry
Presenting Author: Todd D. Vogel, MD
Author Block: Junichi Ohya, MD; Rishi Wadhwa, MD; Leah Carreon, MD, MSc; Anthony L. Asher, MD, FAANS; Steven Glassman, MD; Praveen V. Mummaneni, MD, FAANS
The objective of this analysis was to use a prospective, longitudinal, multi-center outcome registry of patients undergoing surgery for lumbar degenerative disease to assess the incidence and risk factors of 30-day re-operation and 90-day readmission. The QOD Lumbar Spine registry was analyzed. Multivariate binomial regression analysis was performed to identify risk factors for 30-day re-operation and 90-day readmission. A sub-analysis of patients with Medicare coverage 65 years and older were compared to patients younger than 65 years old with Medicare coverage. Continuous variables were compared using unpaired t-tests, and proportions were compared using Fisher’s exact test.
In this analysis of a large prospective, multi-center registry of patients undergoing lumbar surgery, multivariate analysis revealed that the 30-day re-operation rates were similar for Medicare and private insurance patients. The 90-day readmission rates were higher in Medicare beneficiaries, individuals with higher ASA grades and patients with a history of depression. Medicare patients less than 65 years old constituted a subgroup who were significantly more likely to be re-operated within 30 days and to be readmitted within 90 days.
The presenting author provided the following additional comments:
The goal of this paper was to highlight risk factors for short-term reoperation and readmission following lumbar degenerative surgery. The 30-day and three-month time points were chosen based upon quality parameters proposed to offset reimbursement in the future. Additionally, we wanted to establish benchmarks utilizing a prospectively collected database. Administrative databases that have not been validated have a high error rate. Amin et al demonstrated a 25 percent error rate for hospital readmission within 30-days when using a billing database (1). The (N2)QOD database is the only prospectively collected database available that captures multiple markets and multiple practice types to establish national benchmarks for lumbar degenerative spine surgery.
Nearly 10,000 patients were studied in the QOD lumbar registry. We compared privately insured and Medicare insured patients. Additionally, we did a subgroup analysis within the Medicare group comparing patients younger than 65 years old to those older than 65. For 30-day reoperation, multivariate analysis revealed a prolonged operative time at the index case as the only independent risk factor for reoperation. Within the Medicare subgroup analysis, patients under 65 years old were more likely to be reoperated on, were female, overweight and had a higher incidence of depression. For three-month readmission, multivariate analysis demonstrated that Medicare insurance was associated with higher rates of readmission. Additionally, higher ASA grade and a history of depression were independent risk factors for readmission. In a subgroup analysis of Medicare patients, those under the age of 65 were significantly more likely to be readmitted within three months, were more obese, increased fusion surgeries and had higher rates of depression.
Todd D. Vogel, MD
Anthony L. Asher, MD, FAANS
John J. Knightly, MD, FAANS
Praveen V. Mummaneni, MD, FAANS
Understanding Effect of Minimally Invasive Fusion Technologies on Outcomes after Elective Lumbar Fusion: Analysis of N2QOD Registry
Presenting Author: Scott Parker, MD
Author Block: Matthew J. McGirt, MD, FAANS; Praveen V. Mummaneni, MD, FAANS; Jack Knightly, MD, FAANS; Deborah Pfortmiller, PhD; Kevin T. Foley, MD, FAANS; Anthony L. Asher, MD, FAANS
While several smaller studies have suggested minimally invasive surgery (MIS) technologies decrease surgical morbidity and reduce hospital stay, evidence to suggest patient-reported outcome benefits remain lacking. The investigators analyzed the (N2)QOD aggregate dataset (2010-2014) to identify one- and two-level lumbar fusion procedures performed for lumbar stenosis and/or spondylolisthesis with 12-month follow-up. Perioperative and one-year outcomes were compared between cases performed with MIS enabling versus traditional open technologies before and after propensity matching.
Regardless of approach, lumbar fusion was associated with significant and sustained improvements in all measured health domains. When utilized in everyday care by a wide spectrum of spine surgeons, use of MIS technologies was associated with reduced intra-operative blood loss but only a half-day reduction in mean length of hospital stay. MIS was not associated with improved perioperative safety measures or 12-month outcomes.
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