Do Demographic Factors of Spine Surgeons Affect the Rate at Which Spinal Fusion Is Performed on Patients?

Characterizing Negative Online Reviews of Spine Surgeons

DESIGN

Retrospective review.

OBJECTIVE

Characterize negative reviews of spine surgeons in the United States.

SUMMARY

Physician rating websites significantly influence the selection of doctors by other patients. Negative experiences are impacted by various factors, both clinical and nonclinical, geography, and practice structure. The purpose of this study was to evaluate and categorize negative reviews of spine surgeons in the United States, with a focus on surgical versus nonsurgical reviewers.

METHODS

Spine surgeons were selected from available online professional society membership directories. A search for reviews was performed on Healthgrades.com, Vitals.com, and RateMDs.com for the past 10 years. Free response reviews were coded by complaint, and qualitative analysis was performed. χ 2 and Fisher exact tests were used to compare categorical variables, and multiple comparisons were adjusted with Benjamini-Hochberg correction. A binary logistic regression model was performed for the top three most mentioned nonclinical and clinical complaint labels. A P -value <0.05 was considered statistically significant.

RESULTS

A total of 16,695 online reviews were evaluated, including 1690 one-star reviews (10.1%). Among one-star reviews, 64.7% were written by nonsurgical patients and 35.3% by surgical patients. Nonclinical and clinical comments constituted 54.9% and 45.1% of reviews, respectively. Surgeons in the South had more "bedside manner" comments (43.3%, P <0.0001), while Northeast surgeons had more "poor surgical outcome" remarks compared with all other geographic regions (14.4%, P <0.001). Practicing in the South and Northeast were independent predictors of having complaints about "bedside manner" and "poor surgical outcome," respectively.

CONCLUSION

Most one-star reviews of spine surgeons were attributed to nonsurgical patients, who tended to be unsatisfied with nonclinical factors, especially "bedside manner." However, there was substantial geographic variation. These results suggest that spine surgeons could benefit from focusing on nonclinical factors (bedside manner), especially among nonoperative patients, and that regional nuances should be considered in delivering spine care.

LEVEL OF EVIDENCE

Level- 5.

Geographic Distribution in Training and Practice of Academic Neurological and Orthopedic Spine Surgeons in the United States

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

This study aimed to stratify the geographic distribution of academic spine surgeons in the United States, analyzing how this distribution highlights differences in academic, demographic, professional metrics, and gaps in access to spine care.

METHODS

Spine surgeons were identified using American Association of Neurological Surgeons and American Academy of Orthopedic Surgeons databases, categorizing into geographic regions of training and practice. Departmental websites, National Institutes of Health (NIH) RePort Expenditures and Results, Google Patent, and NIH icite databases were queried for demographic and professional metrics.

RESULTS

Academic spine surgeons (347 neurological; 314 orthopedic) are predominantly male (95%) and few have patents (23%) or NIH funding (4%). Regionally, the Northeast has the highest proportion per capita (3.28 surgeons per million), but California is the state with the highest proportion (13%). The Northeast has the greatest regional retention post-residency at 74%, followed by the Midwest (59%). The West and South are more associated with additional degrees. Neurosurgery-trained surgeons hold more additional degrees (17%) than orthopedic surgeons (8%), whereas more orthopedic surgeons hold leadership positions (34%) than neurosurgeons (20%).

CONCLUSIONS

Academic spine surgeons are found at the highest proportion in the Northeast and California; the Northeast has the greatest regional retention. Spine neurosurgeons have more additional degrees, whereas spine orthopedic surgeons have more leadership positions. These results are relevant to training programs looking to correct geographic disparities, surgeons in search of training programs, or students in pursuit of spine surgery.

Practice Variation Within a Single Institution in Management of Degenerative Spondylolisthesis

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to assess variation in care for degenerative spondylolisthesis (DS) among surgeons at the same institution, to establish diagnostic and therapeutic variables contributing to this variation, and to determine whether variation in care changed over time.

SUMMARY OF BACKGROUND DATA

Like other degenerative spinal disorders, DS is prone to practice variation due to the wide array of treatment options. Focusing on a single institution can identify more individualized drivers of practice variation by omitting geographic variability of demographics and socioeconomic factors.

MATERIALS AND METHODS

We collected number of office visits, imaging procedures, injections, electromyography (EMG), and surgical procedures within 1 year after diagnosis. Multivariable logistic regression was used to determine predictors of surgery. The coefficient of variation (CV) was calculated to compare the variation in practice over time.

RESULTS

Patients had a mean 2.5 (±0.6) visits, 1.8 (±0.7) imaging procedures, and 0.16 (±0.09) injections in the first year after diagnosis. Thirty-six percent (1937/5091) of patients had physical therapy in the 3 months after diagnosis. CV was highest for EMG (95%) and lowest for office visits (22%). An additional spinal diagnosis [odds ratio (OR)=3.99, P <0.001], visiting a neurosurgery clinic (OR=1.81, P =0.016), and diagnosis post-2007 (OR=1.21, P =0.010) were independently associated with increased surgery rates. The CVs for all variables decreased after 2007, with the largest decrease seen for EMG (132% vs. 56%).

CONCLUSIONS

While there is variation in the management of patients diagnosed with DS between surgeons of a single institution, this variation seems to have gone down in recent years. All practice variables showed diminished variation. The largest variation and subsequent decrease of variation was seen in the use of EMG. Despite the smaller amount of variation, the rate of surgery has gone up since 2007.

The role of artificial intelligence in orthopaedic surgery

Despite significant advances in orthopaedic surgery, variability still exists between providers and practice locations, and process inefficiencies are found throughout the health care continuum. Evolving technologies, namely artificial intelligence, challenge the status quo by improving patient care in four areas: diagnosis, management, research and systems analysis. Artificial intelligence shows promise in promoting practice efficiency, personalizing patient care, improving institutional research capacity, and expanding high quality orthopaedic care to lower resource settings. Physicians should be involved in the development of artificial intelligence algorithms to ensure that patients derive maximum benefit from new advances while considering the ethical challenges of implementation.

Practice Variation Among Surgeons Treating Lumbar Spinal Stenosis in a Single Institution

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to examine practice variation in the treatment of lumbar spinal stenosis and identify targets for reducing variation.

SUMMARY OF BACKGROUND DATA

Lumbar spinal stenosis is a degenerative condition susceptible to practice variation. Reducing variation aims to improve quality, increase safety, and lower costs. Establishing differences in surgeons' practices from a single institution can help identify personalized variation.

METHODS

We identified adult patients first diagnosed with lumbar spinal stenosis between 2003 and 2015 in three hospitals of the same institution with ICD-9 codes.We extracted number of office visits, imaging procedures, injections, electromyographies (EMGs), and surgery within the first year after diagnosis; physical therapy within the first 3 months after diagnosis. Multivariable logistic regression was used to identify factors associated with surgery. The coefficient of variation (CV) was calculated to compare the variation in practice.

RESULTS

The 10,858 patients we included had an average of 2.5 visits (±1.9), 1.5 imaging procedures (±2.0), 0.03 EMGs (±0.22), and 0.16 injections (±0.53); 36% had at least one surgical procedure and 32% had physical therapy as part of their care. The CV was smallest for number of visits (19%) and largest for EMG (140%).Male sex [odds ratio (OR): 1.23, P < 0.001], seeing an additional surgeon (OR: 2.82, P < 0.001), and having an additional spine diagnosis (OR: 3.71, P < 0.001) were independently associated with surgery. Visiting an orthopedic clinic (OR: 0.46, P < 0.001) was independently associated with less surgical interventions than visiting a neurosurgical clinic.

CONCLUSION

There is widespread variation in the entire spectrum of diagnosis and therapy for lumbar spinal stenosis among surgeons in the same institution. Male gender, seeing an additional surgeon, having an additional spine diagnosis, and visiting a neurosurgery clinic were independently associated with increased surgical intervention. The main target we identified for decreasing variability was the use of diagnostic EMG.

LEVEL OF EVIDENCE

3.

Spinal fusion without instrumentation - Experimental animal study

BACKGROUND

The number and cost of instrumented spinal fusion surgeries have increased rapidly, primarily for the treatment of lumbar segmental instabilities. However, what if the organism itself is able to restore segmental stability over time? This large-animal study using sheep aimed to investigate whether the reparative response after destabilization via facetectomy and nucleotomy without instrumentation can effectively fuse the spinal segment comparable to instrumented standard fusion surgery.

METHODS

The following four surgical interventions were investigated: dorsal fixation via internal fixator, ventral fixation via cage as well as facetectomy and nucleotomy without additional instrumentation. Six months postoperatively, the animals were sacrificed, and the lumbar spines were used for biomechanical tests.

FINDINGS

Spinal stability was restored to the destabilized spinal segments at six months postoperatively and was comparable to the results of conventional surgery via screws and cages. Iatrogenic hypomobilization caused significant reductions in facet joint space and intervertebral disc height of segments at index and adjacent level. Restabilized segments after iatrogenic hypermobilzation also significantly decreased facet joint space and disc height at index level, but revealed no influence on adjacent segments.

INTERPRETATION

These findings in the sheep model question the necessity of costly instrumentation and suggest the alternative possibility of stimulating the reparative capacity of the body in human lumbar spine fusion surgery.