Whether we like it or not, we are living in the era of outcomes studies. Numerous agencies are involved in measuring the outcomes of neurosurgical care and neurosurgeons are increasingly required to define and document the success of their interventions.
Often, those evaluating the value of neurosurgical care have little insight into the issues that arise in the care of our patients and, unfortunately, data from these studies will be used to determine government policy, patient referral and reimbursement. The leadership of the AANS and CNS has recognized both the threat and the opportunity that reliable outcomes studies posed for organized neurosurgery and, in 1997, I was asked to develop this initiative.
The first step was to create a strategic plan for developing a neurosurgical outcomes initiative. The strategic plan included: 1) Organizing an Outcomes Committee with expertise in clinical neurosurgery, outcomes methodology and information technology; 2) initiating educational activities; 3) developing and performing a pilot outcomes study; 4) developing an online outcomes reporting system linked to the official Web site of the AANS and CNS — NEUROSURGERY://ON-CALL® (N://OC® ); and 5) performing online studies using this system.
Over the past two years, we have met these goals. The Outcomes Committee has representatives appointed by the Executive Committees of each of the clinical neurosurgical Sections. The Committee also has members with particular expertise in outcomes methodology and information technology. Consultants from Outcomes Sciences and the AANS Information Services Department also contribute to the overall success of the Committee.
Committee members have developed educational materials for the N://OC® Outcomes page and have published articles in the AANS Bulletin and in Neurosurgery. Outcomes-related topics have been presented at the AANS and CNS Annual Meetings, Section Annual Meetings, and at Professional Development Program (PDP) courses. In fact, a PDP course in Outcomes Methodology is currently being developed, and we plan to continue our educational efforts as the rest of the plan unfolds.
Outcomes Committee Projects
Starting in 1998, our pilot study on the treatment of patients with intracranial aneurysms got underway. The study evaluated patients being treated for ruptured or unruptured intracranial aneurysms by microsurgical or endovascular approaches. Disease-specific data reporting instruments were developed by Issam Awad, MD, and members of the Cerebrovascular Section Outcomes Committee. Pilot centers for the study included academic medical centers and private practice groups. Patient accrual ended on January 31, 1999; however, follow-up on these patients and data analysis will continue through 1999. The aneurysm study will be placed online in an effort to expand the number of neurosurgeons participating in the program. The Committee has worked hard to develop a secure, reliable, online outcomes reporting system linked to the N://OC® Web site. We have reached this goal, and are working closely with Outcomes Sciences and the AANS Information Services Department to keep the submission of data safe and confidential. A full discussion of the security systems developed for this outcomes project can be found on the N://OC® outcomes page.
Online Studies Available
At present, there are two online studies available to all members of the AANS and CNS. The first is a simple, one-page outcomes reporting instrument that can be used for any neurosurgical diagnosis or procedure — the neurosurgical report card. The report card allows neurosurgeons to track basic outcomes measures, such as length of hospital stay, mortality, postoperative infectiion and unplanned readmission or return to the operating room by CPT and ICD-9 codes. Once the database is established, the individual neurosurgeon can compare his or her data to the overall database.
A more in-depth study on the treatment of patients with carotid artery stenosis also is online. The study, which began in January 1999, evaluates the clinical, functional and lesional outcomes of patients with carotid artery stenosis treated by carotid endarterectomy or angioplasty and stenting. The outcomes reporting system allows any member of the AANS or CNS to enter all relevant data online. It is essential that every neurosurgeon submitting data to the study report on all of the patients they treat. There is no cost involved for AANS or CNS members and there are no patient or surgeon identifiers on the database. The identification code is kept at the AANS National Office and can be accessed through the Internet, making submission of data via this system safe and confidential.
The next study to go online will evaluate the treatment of patients with lumbar disc disease. Paul McCormick, MD, and other members of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves have developed the reporting instruments for this study, which should be online this spring. Once again, participation by all AANS and CNS members is strongly encouraged.
Meeting AANS Members Needs
The members of the Outcomes Committee are committed to developing the necessary tools for neurosurgeons to participate in outcomes research in the most cost-effective manner. We are excited about the potential that exists for generating national and international databases, determining the best practices and gaining insight into the value of our neurosurgical interventions. We hope that our neurosurgical colleagues will be as excited as we are and become involved in this venture. If anyone has questions that are not addressed on the N://OC® outcomes page, please contact me via e-mail at [email protected].
Robert E. Harbaugh, MD, is a neurosurgeon at Dartmouth-Hitchcock Medical Center, nine-year AANS member, and Chairman of the AANS/CNS Outcomes Initiative — a team convened to provide tools to AANS/CNS members for use within their practice to measure, monitor and manage selected outcomes.