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Shetty KD, Chen PG, Brara HS, Anand N, Skaggs DL, Calsavara VF, Qureshi NS, Weir R, McKelvey K, Nuckols TK. Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter? Int J Qual Health Care 2024; 36:mzad109. [PMID: 38156345 PMCID: PMC10849168 DOI: 10.1093/intqhc/mzad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/30/2023] [Accepted: 12/28/2023] [Indexed: 12/30/2023] Open
Abstract
For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.
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Affiliation(s)
- Kanaka D Shetty
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Peggy G Chen
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Harsimran S Brara
- Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Neel Anand
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - David L Skaggs
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | | | - Nabeel S Qureshi
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Rebecca Weir
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Karma McKelvey
- Rocky Vista University, Montana College of Osteopathic Medicine, 4130 Rocky Vista Way, Billings, Montana 59106, USA
| | - Teryl K Nuckols
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Marjamaa J, Huttunen J, Kankare J, Malmivaara A, Pernaa K, Salmenkivi J, Pekkanen L. The Finnish spine register (FinSpine): development, design, validation and utility. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3731-3743. [PMID: 37718342 DOI: 10.1007/s00586-023-07874-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 07/27/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE Our aim was to develop a nationwide, computer-based, Spine Register (FinSpine) for monitoring surgical activity, quality of surgery, long-term outcomes, and effectiveness of treatment. In this paper, we describe our experiences in the development and implementation of the register. METHODS The register was developed by a steering group, consisting of orthopedic surgeons and neurosurgeons from the whole country. We strived to develop a register which would be in active use by spine surgeons and enable collection of Patient Reported Outcome and Experience Measures (PROMs and PREMs) automatically and prospectively. We are actively promoting the use of the register in order to gain a nationwide coverage and achieve high response-rates from both surgeons and patients. RESULTS The use of FinSpine started in 2016 and it has been granted continuous funding from the Finnish Institute for Health and Welfare from the 1st of January 2023 onwards. Currently the register is used by 19/23 (83%) public hospitals and the use is expanding to private hospitals as well. The response-rate of surgeons is currently 80%. The response-rate of patients is on average 56% but reaches up to 90% in hospitals using register-coordinators. CONCLUSION The use of FinSpine is increasing. By gaining a larger coverage and completeness, the data can be used for research purposes which we believe will influence decision making and ultimately improve the outcomes and quality of life of the patients. Comparison with other national spine registers is possible, since FinSpine includes similar baseline characteristics and outcome measures (e.g., ODI, EQ-5D, VAS).
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Affiliation(s)
- Johan Marjamaa
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland.
| | - Jukka Huttunen
- Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Jyrki Kankare
- Department of Orthopedic Surgery, Helsinki University Hospital, Helsinki, Finland
| | | | - Katri Pernaa
- Department of Orthopedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Jyrki Salmenkivi
- Department of Orthopedic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Liisa Pekkanen
- Department of Orthopedic Surgery, Central Finland Central Hospital, Jyväskylä, Finland
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Koivunen K, Pernaa KI, Saltychev M. Back pain and radicular pain after lumbar microdiscectomy. BMC Surg 2023; 23:210. [PMID: 37496020 PMCID: PMC10369687 DOI: 10.1186/s12893-023-02114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023] Open
Abstract
PURPOSE It is generally expected that lumbar microdiscectomy affects radicular leg pain, but not so much local back pain. The primary objective was to evaluate if the trajectories of changes in pain severity follow similar patterns for back and radicular leg pain after lumbar microdiscectomy. The secondary objective was to investigate the associations between some preoperative parameters and the patterns of these trajectories. METHODS Register-based retrospective study of 353 patients undergoing microdiscectomy in the lumbar spine. Linear mixed modelling was applied. RESULTS The average age of the participants was 46 years and 44% were women. The developmental trajectories were similar for both back and leg pain. Pain level decrease during the first year after the surgery, slightly worsening later. No statistically significant interactions were detected of preoperative pain duration or severity, sex or age on the shapes of the trajectories. For every analyzed grouping factor, the 95% confidence intervals overlapped at every postoperative time point with one exception - worse preoperative back pain was statistically significantly associated with worse pain at three months and at the end of the two-year follow-up. CONCLUSION After microsurgical discectomy, developmental curves for both back and radicular leg pain demonstrated similar patterns. Pain intensity decreased during the first year after the surgery. and slightly increased after that remaining, however, below the preoperative level. Age, sex, preoperative pain duration or preoperative intensity of leg pain were not associated with significant differences in the trajectories of pain severity after the surgery. In this study, severe preoperative back pain was the only factor, which was significantly associated with worse postoperative trajectory of pain intensity.
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Affiliation(s)
| | - Katri I Pernaa
- Department of Orthopedics, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikhail Saltychev
- Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, PO Box 528, Turku, FI-20701, Finland.
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Tesch F, Lange T, Dröge P, Günster C, Flechtenmacher J, Lembeck B, Kladny B, Wirtz DC, Niethard FU, Schmitt J. Indication for spinal surgery: associated factors and regional differences in Germany. BMC Health Serv Res 2022; 22:1109. [PMID: 36050682 PMCID: PMC9438246 DOI: 10.1186/s12913-022-08492-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Rising surgery rates have raised questions about the indications for spinal surgery. The study investigated patient-level and regional factors associated with spinal surgery for patients with spinal diseases. METHODS We undertook a cohort study based on routine healthcare data from Germany of 18.4 million patients within 60.9 million episodes of two patient-years before a possible spinal surgery in the time period 2008 to 2016. Using a Poisson model, the effects of a broad range of patient-related (sociodemographic, morbidity, social status), disease- and healthcare-related (physicians' specialty, conservative treatments) and regional variables were analyzed. RESULTS There was substantial regional heterogeneity in the occurrence of spinal surgery which decreased by only one quarter when controlling for the various determinants assessed. Previous musculoskeletal and mental health disorders as well as physical therapy were associated with a lower probability of surgery in the fully-adjusted model. Prescriptions for pain medication and consultations of specialists were associated with a higher probability of surgery. However, the specific severity of the vertebral diseases could not be taken into account in the analysis. Furthermore, a substantial proportion of patients with surgery did not receive a consultation with an outpatient specialist (29.5%), preoperative diagnostics (37.0%) or physical therapy (48.3%) before hospital admission. CONCLUSION This large study on spinal diseases in Germany highlights important patterns in medical care of spinal diseases and their association with the probability of spinal surgery. However, only a relatively small proportion of the regional heterogeneity in spinal surgery could be explained by the extensive consideration of confounders, which suggests the relevance of other unmeasured factors like physicians' preferences.
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Affiliation(s)
- Falko Tesch
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
| | - Toni Lange
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
| | - Patrik Dröge
- Allgemeine Ortskrankenkasse (AOK) Research Institute, Berlin, Germany
| | - Christian Günster
- Allgemeine Ortskrankenkasse (AOK) Research Institute, Berlin, Germany
| | | | - Burkhard Lembeck
- German Professional Association for Orthopedics and Trauma (BVOU), Berlin, Germany
| | - Bernd Kladny
- m&i Fachklinik Herzogenaurach, Herzogenaurach, Germany
- German Society for Orthopedics and Trauma (DGOU), Berlin, Germany
| | - Dieter Christian Wirtz
- German Society for Orthopedics and Trauma (DGOU), Berlin, Germany
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Bonn, Germany
| | | | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, 01307 Dresden, Germany
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Joelson A, Sigmundsson FG, Karlsson J. Stability of SF-36 profiles between 2007 and 2016: A study of 27,302 patients surgically treated for lumbar spine diseases. Health Qual Life Outcomes 2022; 20:92. [PMID: 35672781 PMCID: PMC9172105 DOI: 10.1186/s12955-022-01999-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/25/2022] [Indexed: 11/11/2022] Open
Abstract
Background Previous studies have shown that patients with different lumbar spine diseases report different SF-36 profiles, but data on the stability of the SF-36 profiles are limited. The primary aim of the current study was to evaluate the stability of the SF-36 profile for lumbar spine diseases. Methods Patients, surgically treated between 2007 and 2016 for three lumbar spine diseases, lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS), LSS without DS, and lumbar disk herniations (LDH), were identified in the Swedish spine register. Preoperative and 1 year postoperative SF-36 data for a total of 27,302 procedures were available for analysis. The stability of the SF-36 profiles over the 10-year period was evaluated using graphical exploration, linear regression, difference in means, and 95% confidence intervals. The responsiveness of the SF-36 domains to surgical treatment was evaluated using the standardized response mean (SRM).
Results LSS and LDH have different SF-36 profiles. LSS with DS and LSS without DS have similar SF-36 profiles. The preoperative and the 1 year postoperative SF-36 profiles were stable from 2007 to 2016 for all three diagnoses. There were no major changes in the effect size of change (SRM) during the study period for all three diagnoses. For LSS with DS, the number of fusions peaked in 2010 and then decreased. The postoperative SF-36 profiles for LSS with DS were unaffected by changes in surgical treatment trends. Conclusions Patients with lumbar spinal stenosis and lumbar disk herniations have different SF-36 profiles. Concomitant degenerative spondylolisthesis had no impact on the SF-36 profile of lumbar spinal stenosis. Adding fusion to the decompression did not alter the postoperative SF-36 profile of lumbar spinal stenosis. The SF-36 health profiles are stable from a 10 years perspective. Supplementary Information The online version contains supplementary material available at 10.1186/s12955-022-01999-7.
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