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| William T. Couldwell, MD, is editor of the AANS Bulletin |
Performance measures selected to evaluate neurosurgeon performance in patient care should be based on published scientific evidence. The problem arises when treatment algorithms are standardized without the corresponding base of strong scientific evidence.
While treatment guidelines for the management of head trauma, spine injury and lumbar fusion exist in our literature, careful perusal of these indicate that class I or class II evidence is lacking in many of the clinical treatment scenarios. Class III evidence, if present, merely denotes “options” for treatment. Will such weak evidence provide a yardstick by which to measure physician performance? Neurosurgeons must be aware of the negative potential for P4P and the limited financial impact (2 percent of an already deeply discounted fee).
Another cautionary note for guidelines: Rather than improving care for patients, they may be misused at trial in a naive and simplistic fashion and thus become a potential liability for neurosurgeons. Plaintiff attorneys may advocate to juries, chiefly composed of lay members of the public, that guidelines can be used to measure a neurosurgeon’s adherence of care to established practice (thus applying the cookbook medicine analogy). This issue is thoughtfully reviewed by Fernando Diaz, MD.
The problems in establishing strong scientific evidence to support a “standard of care” (class I evidence by randomized clinical trial), or true “guideline” (class II evidence) in a small specialty such as neurosurgery are well discussed by Robert Harbaugh, MD. Given the limitations of using randomized clinical trials to develop robust guidelines in our specialty, he proposes the development of a procedure-specific registry to collate data in a nonpunitive environment. This would enable neurosurgeons to monitor outcomes while looking at aggregate data and would provide a repository of data for later analysis to determine optimal outcome related to specific practice.