Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis

Value Defects in Spine Surgery: How to Reduce Wasteful Care and Improve Value

Technological innovation has advanced the efficacy of spine surgery for patients; however, these advances do not consistently translate into clinical effectiveness. Some patients who undergo spine surgery experience continued chronic back pain and other complications that were not present before the procedure. Defects in healthcare value, such as the lack of clinical benefit from spine surgery, are, unfortunately, common, and the US healthcare system spends $1.4 trillion annually on value defects. In this article, we examine how avoidable complications, postacute healthcare use, revision surgeries, and readmissions among spine surgery patients contribute to $67 million of wasteful spending on value defects. Furthermore, we estimate that almost $27 million of these costs could be recuperated simply by redirecting patients to facilities referred to as centers of excellence. In total, quality improvement efforts are costly to implement but may only cost about $36 million to fully correct the $67 million in finances misappropriated to value defects. The objectives of this article are to present an approach to eliminate defects in spine surgery, including a center-of-excellence framework for eliminating defects specific to this group of procedures.

Evaluation of "appropriate use criteria" for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study

INTRODUCTION

Selecting patients with lumbar degenerative spondylolisthesis (LDS) for surgery is difficult. Appropriate use criteria (AUC) have been developed to clarify the indications for LDS surgery but have not been evaluated in controlled studies.

METHODS

This prospective, controlled, multicentre study involved 908 patients (561 surgical and 347 non-surgical controls; 69.5 ± 9.7y; 69% female), treated as per normal clinical practice. Their appropriateness for surgery was afterwards determined using the AUC. They completed the Core Outcome Measures Index (COMI) at baseline and 12 months' follow-up. Multiple regression adjusting for confounders evaluated the influence of appropriateness designation and treatment received on the 12-month COMI and achievement of MCIC (≥ 2.2-point-reduction).

RESULTS

As per convention, appropriate (A) and uncertain (U) groups were combined for comparison with the inappropriate (I) group. For the adjusted 12-month COMI, the benefit of surgery relative to non-surgical care was not significantly greater for the A/U than the I group (p = 0.189). There was, however, a greater treatment effect of surgery for those with higher baseline COMI (p = 0.035). The groups' adjusted probabilities of achieving MCIC were: 83% (A/U, receiving surgery), 71% (I, receiving surgery), 50% (A/U, receiving non-surgical care), and 32% (I, receiving non-surgical care).

CONCLUSIONS

A/U patients receiving surgery had the highest chances of achieving MCIC, but the AUC were not able to identify which patients had a greater treatment effect of surgery relative to non-surgical care. The identification of other characteristics that predict a greater treatment effect of surgery, in addition to baseline COMI, is required to improve decision-making.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons

BACKGROUND

Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis.

METHODS

The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree).

RESULTS

Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4).

CONCLUSIONS

Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

How well can the clinician appraise the patient's perception of the severity and impact of their back problem?

PURPOSE

A main concern of patients with back problems is pain and its impact on function and quality of life. These are subjective phenomena, and should be probed during the clinical consultation so that the physician can ascertain the extent of the problem. This study evaluated the agreement between clinicians' and patients' independent ratings of patient status on the Core Outcome Measures Index (COMI).

METHODS

This was an analysis of the data from 5 spine specialists and 108 patients, in two centres. Prior to the consultation, the patient completed the COMI. After the consultation, the clinician (blind to the patient's version) also completed a COMI. Concordance was assessed by % agreement, Kappa values, Bland-Altman plots, Spearman rank, Intraclass Correlation Coefficients and comparisons of mean values, as appropriate.

RESULTS

Agreement regarding the "main problem" (back pain, leg/buttock pain, sensory disturbances, other) was 83%, Kappa = 0.70 (95%CI 0.58-0.81). Moderate/strong correlations were found between the doctors' and patients' COMI-item ratings (0.48-0.74; p < 0.0001), although compared with the patients' ratings the doctors systematically underestimated absolute values for leg pain (p = 0.002) and dissatisfaction with symptom state (p = 0.002), and overestimated how much the patient's function was impaired (p = 0.029).

CONCLUSION

The doctors were able to ascertain the location of the main problem and the multidimensional outcome score with good accuracy, but some individual domains were systematically underestimated (pain, symptom-specific well-being) or overestimated (impairment of function). More detailed/direct questioning on these domains during the consultation might deliver a better appreciation of the impact of the back problem on the patient's daily life.