The Affordable Care Act: a case study for understanding and applying complexity concepts to health care reform

A Sample of the Future: Digital Health and Near-Patient Testing

We, a nurse and a laboratory director, share our experience supporting a research study that employed a digital health application and a rapid test for severe acute respiratory syndrome coronavirus 2 and the implications of this approach for health care delivery.

Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery?

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery.

OBJECTIVE

To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery.

METHODS

The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization.

RESULTS

We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score.

CONCLUSION

The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.

Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion

BACKGROUND

Hospitals seek to reduce costs and improve patient outcomes by decreasing length of stay (LOS), 30-day all-cause readmissions, and preventable complications. We evaluated hospital-reported outcome measures for elective single-level anterior cervical discectomy and fusions (ACDFs) between tertiary (TH) and community hospitals (CH) to determine location-based differences in complications, LOS, and overall costs.

METHODS

Patients undergoing elective single-level ACDF in a 1-year period were retrospectively reviewed from a physician-driven database from a single medical system consisting of 1 TH and 4 CHs. Adult patients who underwent elective single-level ACDF were included. Patients with trauma, tumor, prior cervical surgery, and infection were excluded. Outcomes measures included all-cause 30-day readmissions, preventable complications, LOS, and hospital costs.

RESULTS

A total of 301 patients (60 TH, 241 CH) were included. CHs had longer LOS (1.25 ± 0.50 versus 1.08 ± 0.28 days, P = .01). There were no differences in complication and readmission rates between hospital settings. CH, orthopaedic subspecialty, female sex, and myelopathy were predictors for longer LOS. Overall, costs at the TH were significantly higher than at CHs ($17 171 versus $11 737; Δ$ = 5434 ± 3996; P < .0001). For CHs, the total costs of drugs, rooms, supplies, and therapy were significantly higher than at the TH. TH status, orthopaedic subspecialty, and myelopathy were associated with higher costs.

CONCLUSION

Patients undergoing single-level ACDFs at CHs had longer LOS, but similar complications and readmission rates as those at the TH. However, cost of ACDF was 1.5 times greater in the TH. To improve patient outcomes, optimize value, and reduce hospital costs, modifiable factors for elective ACDFs should be evaluated.

LEVEL OF EVIDENCE

3.

Artificial Intelligence and Robotics in Spine Surgery

STUDY DESIGN

Narrative review.

OBJECTIVES

Artificial intelligence (AI) and machine learning (ML) have emerged as disruptive technologies with the potential to drastically affect clinical decision making in spine surgery. AI can enhance the delivery of spine care in several arenas: (1) preoperative patient workup, patient selection, and outcome prediction; (2) quality and reproducibility of spine research; (3) perioperative surgical assistance and data tracking optimization; and (4) intraoperative surgical performance. The purpose of this narrative review is to concisely assemble, analyze, and discuss current trends and applications of AI and ML in conventional and robotic-assisted spine surgery.

METHODS

We conducted a comprehensive PubMed search of peer-reviewed articles that were published between 2006 and 2019 examining AI, ML, and robotics in spine surgery. Key findings were then compiled and summarized in this review.

RESULTS

The majority of the published AI literature in spine surgery has focused on predictive analytics and supervised image recognition for radiographic diagnosis. Several investigators have studied the use of AI/ML in the perioperative setting in small patient cohorts; pivotal trials are still pending.

CONCLUSIONS

Artificial intelligence has tremendous potential in revolutionizing comprehensive spine care. Evidence-based, predictive analytics can help surgeons improve preoperative patient selection, surgical indications, and individualized postoperative care. Robotic-assisted surgery, while still in early stages of development, has the potential to reduce surgeon fatigue and improve technical precision.

Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system.

METHODS

Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs.

RESULTS

A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions (P < .001) per level fused; the CH performed more interbody fusions (P = .007). Cost of performing microdiscectomy (P < .001) and laminectomy (P = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy (P < .001) and laminectomy with single-level fusion (P < .001), but trended toward significance for laminectomy without fusion (P = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH (P = .019).

CONCLUSIONS

We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.

Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors

BACKGROUND

Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported.

OBJECTIVE

To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors.

METHODS

Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost).

RESULTS

A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314.

CONCLUSION

Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.

Telephone-Based Intervention to Improve Rehabilitation Engagement After Spinal Stenosis Surgery: A Prospective Lagged Controlled Trial

BACKGROUND

Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures.

METHODS

In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group.

RESULTS

By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group.

CONCLUSIONS

Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Bending the Cost Curve-Establishing Value in Spine Surgery

BACKGROUND

As publically promoted by all stakeholders in health care reform, prospective outcomes registry platforms lie at the center of all current evidence-driven value-based models.

OBJECTIVE

To demonstrate the variability in outcomes and cost at population level and individual patient level for patients undergoing spine surgery for degenerative diseases.

METHODS

Retrospective analysis of prospective longitudinal spine registry data was conducted. Baseline and postoperative 1-year patient-reported outcomes were recorded. Previously published minimal clinically important difference for Oswestry Disability Index (14.9) was used. Back-related resource utilization and quality-adjusted life years (QALYs) were assessed. Variations in outcomes and cost were analyzed at population level and at the individual patient level.

RESULTS

A total of 1454 patients were analyzed. There was significant improvement in patient-reported outcomes at postoperative 1 year ( P < .0001). For patients demonstrating health benefit at population level, 12.5%, n = 182 of patients experienced no gain from surgery and 38%, n = 554 failed to achieve minimal clinically important difference. Mean 1-year QALY-gained was 0.29; 18% of patients failed to report gain in QALY. For patients with 2-year follow-up, surgery resulted in 0.62 QALY-gained at average direct cost of $28 953. A wide variation in both QALY-gained and cost was observed.

CONCLUSION

Spine treatments that on average are cost-effective may have wide variability in value at the individual patient level. The variability demonstrated here represents an opportunity, through registries, to identify specific care that may be less effective, and refine patient-specific care delivery and indications to drive overall group-level treatment value. Understanding value of spine care at an individualized as well as population level will allow clinicians, and eventually payers, to better target resources for improving care for nonresponders, ultimately driving up the average health for the whole population.

Spinal Surgeon Variation in Single-Level Cervical Fusion Procedures: A Cost and Hospital Resource Utilization Analysis

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To compare perioperative costs and outcomes of patients undergoing single-level anterior cervical discectomy and fusions (ACDF) at both a service (orthopedic vs. neurosurgical) and individual surgeon level.

SUMMARY OF BACKGROUND DATA

Hospital systems are experiencing significant pressure to increase value of care by reducing costs while maintaining or improving patient-centered outcomes. Few studies have examined the cost-effectiveness cervical arthrodesis at a service level.

METHODS

A retrospective review of patients who underwent a primary 1-level ACDF by eight surgeons (four orthopedic and four neurosurgical) at a single academic institution between 2013 and 2015 was performed. Patients were identified by Diagnosis-Related Group and procedural codes. Patients with the ninth revision of the International Classification of Diseases coding for degenerative cervical pathology were included. Patients were excluded if they exhibited preoperative diagnoses or postoperative social work issues affecting their length of stay. Comparisons of preoperative demographics were performed using Student t tests and chi-squared analysis. Perioperative outcomes and costs for hospital services were compared using multivariate regression adjusted for preoperative characteristics.

RESULTS

A total of 137 patients diagnosed with cervical degeneration underwent single-level ACDF; 44 and 93 were performed by orthopedic surgeons and neurosurgeons, respectively. There was no difference in patient demographics. ACDF procedures performed by orthopedic surgeons demonstrated shorter operative times (89.1 ± 25.5 vs. 96.0 ± 25.5 min; P = 0.002) and higher laboratory costs (Δ+$6.53 ± $5.52 USD; P = 0.041). There were significant differences in operative time (P = 0.014) and labor costs (P = 0.034) between individual surgeons. There was no difference in total costs between specialties or individual surgeons.

CONCLUSION

Surgical subspecialty training does not significantly affect total costs of ACDF procedures. Costs can, however, vary between individual surgeons based on operative times. Variation between individual surgeons highlights potential areas for improvement of the cost effectiveness of spinal procedures.

LEVEL OF EVIDENCE

4.

Surgical Resection of Intradural Extramedullary Spinal Tumors: Patient Reported Outcomes and Minimum Clinically Important Difference

STUDY DESIGN

Analysis of prospectively collected longitudinal web-based registry data.

OBJECTIVE

To determine relative validity, responsiveness, and minimum clinically important difference (MCID) thresholds in patients undergoing surgery for intradural extramedullary (IDEM) spinal tumors.

SUMMARY OF BACKGROUND DATA

Patient-reported outcomes (PROs) are vital in establishing the value of care in spinal pathology. There is limited availability of prospective, quality studies reporting PROs for IDEM spine tumors.

METHODS

. A total of 40 patients were analyzed. Baseline, postoperative 3-month, and 12-month PROs were recorded: Oswestry Disability Index or Neck disability Index (ODI/NDI), Quality of life EuroQol-5D (EQ-5D), Short Form-12 (SF-12), Numeric Rating Scale (NRS)-pain scores. Responders were defined as those who achieved a level of improvement one or two, after surgery, on health transition index (HTI) of SF-36. Receiver-operating characteristic curves were generated to assess the validity of PROs, and the difference between standardized response means (SRMs) in responders versus nonresponders was utilized to determine the relative responsiveness of each PRO measure. MCID thresholds were derived using previously reported minimal detectable change approach.

RESULTS

A significant improvement across all PROs at 3-months and 12-months follow up was noted. The derived MCID thresholds were 13.9 points: ODI/NDI, 0.14 quality adjusted life years: EQ-5D, 2.8 points: SF-12PCS and 10.7 points: SF-12MCS, 1.9 points: NRS-back/neck pain, and 1.8 points: NRS-leg/arm pain. SF-12PCS was most accurate discriminator of meaningful improvement (area under the curve, AUC-0.83) and most responsive (SRM-1.36) to postoperative improvement. EQ-5D, ODI/NDI, NRS-pain scores were all accurate discriminator (AUC-0.7-0.8) and responsive measures (0.97-0.67) of meaningful postoperative improvement. SF-12MCS was neither a valid discriminator (AUC-0.48) nor a responsive measure (SRM: -1.5) of outcome.

CONCLUSION

Surgical resection of IDEM spinal tumors provides significant and sustained improvement in quality of life, general health, disability, and pain at 12-month after surgery. The surgically resected IDEM-specific clinically meaningful thresholds are reported. All the PROs reported in this study can accurately discriminate responders and nonresponder based on SF-36 HTI index except for SF-12 MCS.

LEVEL OF EVIDENCE

3.