Spine centers of excellence: applications for the ambulatory care setting

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.

Spine centers of excellence: a systematic review and single-institution description of a spine center of excellence

BACKGROUND

Centers of excellence (COEs) are interdisciplinary healthcare organizations created with the goal of improving health/economic outcomes in medical treatment for both individuals and health systems, compared to traditionally structured counterparts. Multiple studies have highlighted both societal/individual burdens associated with back pain, underscoring the importance of identifying new avenues for improving both cost/clinical outcomes for this patient population. Here, we utilize available literature to better characterize the features of a spine COE at a tertiary care center and determine the impact of COEs on patient satisfaction and outcomes.

METHODS

A systematic review describing spine COEs was performed. PubMed, OVID, Cochrane, Web of Science, and Scopus were utilized for electronic literature search. Data including institution, department, pathologies treated, patient satisfaction scores, patient outcomes, and descriptions of the COE, were extracted and analyzed by two reviewers per full-text article. Inclusion criteria consisted of literature describing the organization, purpose, or outcomes of a spine COE, all publication types (except technical/operative report), adult or pediatric patients, publication from inception through September 2021. Exclusion criteria consisted of articles that do not discuss spinal COEs, technical/operative reports, studies unavailable in English language, unavailable full text, or non-human subjects. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the included studies.

RESULTS

Five hundred and sixty-seven unique publications were obtained from the literature search. Of these articles, 20 were included and 547 were excluded based on inclusion and exclusion criteria. Following full-text review of the 20 publications, 6 contained pertinent data. Quantitative data comparing COE versus non-COE was contradictory in comparing complication rates and episodic costs. Qualitative data included descriptions of spine COE features and cited improved patient care, technical advancements, and individualized care paths as positive aspects of the COE model. Mean risk of bias assessment was 3.67.

DISCUSSION

There is little evidence regarding if spine COEs provide an advantage over traditionally organized facilities. The current number and heterogeneity of publications, and lack of standardized metrics used to define a spinal COE are limiting factors. Spinal COE may offer higher value care, reduced complication rates and advancements in knowledge and technical skill.

The primary spine practitioner as a new role in healthcare systems in North America

Background

In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies.

Main body

The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly.

Conclusion

Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.