The present and future of quality measures and public reporting in neurosurgery

Preoperative predictors of prolonged hospitalization in patients undergoing lateral lumbar interbody fusion

PURPOSE

We aim to examine the preoperative factors associated with increased postoperative length of stay in patients undergoing LLIF in the hospital setting.

METHODS

Patient demographics, perioperative characteristics, and patient-reported outcome measures (PROMs) were collected from a single-surgeon database. Patients undergoing LLIF in the hospital setting were separated into postoperative LOS <48 h (H) and LOS ≥ 48H. Univariate analysis for preoperative characteristics was utilized to determine covariates for multivariable logistic regression. Multivariable logistic regression was then utilized to determine significant predictors of extended postoperative length of stay. Secondary univariate analysis of inpatient complications, operative, and postoperative characteristics were calculated to determine postoperative factors associated with prolonged hospitalization.

RESULTS

Two-hundred and forty patients were identified with 115 patients' LOS ≥ 48H. Univariate analysis identified age/Charlson Comorbidity Index (CCI) score/gender/insurance type/number of contiguous fused levels/preoperative PROMs of Visual Analog Scale (VAS) back/VAS leg/Patient-Reported Outcomes Measurement Information System (PROMIS-PF)/Oswestry Disability Index (ODI)/degenerative spondylolisthesis diagnoses/foraminal stenosis/central stenosis for multivariable logistic regression. Multivariable logistic regression calculated significant positive predictors of LOS ≥ 48H to be age/3-level fusion/preoperative ODI scores. Negative predictors of LOS ≥ 48H were the diagnosis of foraminal stenosis/preoperative PROMIS-PF/male gender. The secondary analysis determined that patients with longer operative time/estimated blood loss/transfusion/postoperative day 0 and 1 pain and narcotic consumption/complications of altered mental status/postoperative anemia/fever/ileus/urinary retention were associated with prolonged hospitalization.

CONCLUSION

Older patients undergoing LLIF with greater preoperative disability and 3-level fusion were more likely to require prolonged hospitalization. Male patients with higher preoperative physical function and who were diagnosed with foraminal stenosis were less likely to require prolonged hospitalization.

Association of the classification of intraoperative adverse events (ClassIntra) with complications and neurological outcome after neurosurgical procedures: a prospective cohort study

PURPOSE

To analyze the reliability of the classification of intraoperative adverse events (ClassIntra) to reflect intraoperative complications of neurosurgical procedures and the potential to predict the postoperative outcome including the neurological performance. The ClassIntra classification was recently introduced and found to be reliable for assessing intraoperative adverse events and predicting postoperative complications across different surgical disciplines. Nevertheless, its potential role for neurosurgical procedures remains elusive.

METHODS

This is a prospective, monocentric cohort study assessing the ClassIntra in 422 adult patients who underwent a neurosurgical procedure and were hospitalized between July 1, 2021, to December 31, 2021. The primary outcome was the occurrence of intraoperative complications graded according to ClassIntra and the association with postoperative outcome reflected by the Clavien-Dindo classification and comprehensive complication index (CCI). The ClassIntra is defined as intraoperative adverse events as any deviation from the ideal course on a grading scale from grade 0 (no deviation) to grade V (intraoperative death) and was set at sign-out in agreement between neurosurgeon and anesthesiologist. Secondary outcomes were the neurological outcome after surgery as defined by Glasgow Coma Scale (GCS), modified Rankin scale (mRS), Neurologic Assessment in Neuro-Oncology (NANO) scale, National Institute Health of Strokes Scale (NIHSS), and Karnofsky Performance Score (KPS), and need for unscheduled brain scan.

RESULTS

Of 442 patients (mean [SD] age, 56.1 [16.2]; 235 [55.7%] women and 187 [44.3%] men) who underwent a neurosurgical procedure, 169 (40.0%) patients had an intraoperative adverse event (iAE) classified as ClassIntra I or higher. The NIHSS score at admission (OR, 1.29; 95% CI, 1.03-1.63, female gender (OR, 0.44; 95% CI, 0.23-0.84), extracranial procedures (OR, 0.17; 95% CI, 0.08-0.61), and emergency cases (OR, 2.84; 95% CI, 1.53-3.78) were independent risk factors for a more severe iAE. A ClassIntra ≥ II was associated with increased odds of postoperative complications classified as Clavien-Dindo (p < 0.01), neurological deterioration at discharge (p < 0.01), prolonged hospital (p < 0.01), and ICU stay (p < 0.01). For elective craniotomies, severity of ClassIntra was associated with the CCI (p < 0.01) and need for unscheduled CT or MRI scan (p < 0.01). The proportion of a ClassIntra ≥ II was significantly higher for emergent craniotomies (56.2%) and associated with in-hospital mortality, and an unfavorable neurological outcome (p < 0.01).

CONCLUSION

Findings of this study suggest that the ClassIntra is sensitive for assessing intraoperative adverse events and sufficient to identify patients with a higher risk for developing postoperative complications after a neurosurgical procedure.

The Hawthorne Effect: Quality and Outcomes in Neurosurgery

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

Implementing Health Care Quality Measures in Electronic Health Records: A Conceptual Model

BACKGROUND/OBJECTIVES

There is significant literature on the development and validation of quality measures, but comparably less on their implementation into learning health systems. Electronic Health Records (EHRs) have made vast amounts of data available for quality improvement purposes. In this paper we describe a conceptual model for EHR implementation of quality measures.

DESIGN

The model involves five steps: (1) select a measure; (2) define measure criteria; (3) validate criteria and measurement process; (4) improve recording of measure-related activity; and (5) engage quality improvement processes. The model was used to develop and implement a quality measure in the Home-Based Medical Care (HBMC) setting.

SETTING

Harris Health House Call Program (HHHC) provides primary medical and palliative care for homebound patients in Houston.

PARTICIPANTS

Four-hundred twenty-four primary care patients followed in the HHHC.

MEASUREMENT

Completion rate of the 9-item Patient Health Questionnaire (PHQ-9) within the Electronic Health Record of newly enrolled HHHC patients.

RESULTS

Use of the conceptual model to guide implementation of a quality measure of depression screening in a HMBC practice was successful. Additional components of early leadership and clinician buy-in were required, as well as strong relationships with IT to ease implementation and limit disruptions in clinicians' work-flow.

CONCLUSION

This conceptual model was feasible for guiding implementation of a quality measure for depression care of HBMC patients, and it can guide broader implementation of EHR-based quality measures in the future.

How Do You Measure Up: Quality Measurement for Improving Patient Care and Establishing the Value of Infectious Diseases Specialists

The shift from volume-based to value-based reimbursement has created a need for quantifying clinical performance of infectious diseases (ID) physicians. Nationally recognized ID specialty-specific quality measures will allow stakeholders, such as patients and payers, to determine the value of care provided by ID physicians and will promote clinical quality improvement. Few ID-specific measures have been developed; herein, we provide an overview of the importance of quality measurement for ID, discuss issues in quality measurement specific to ID, and describe standards by which candidate quality measures can be evaluated. If ID specialists recognize the need for quality measurement, then ID specialists can direct ID-related quality improvement, quantify the impact of ID physicians on patient outcomes, compare their performance to that of peers, and convey to stakeholders the value of the specialty.

Analysis of Anterior Cervical Discectomy and Fusion Healthcare Costs via the Value-Driven Outcomes Tool

BACKGROUND

Examining the costs of single- and multilevel anterior cervical discectomy and fusion (ACDF) is important for the identification of cost drivers and potentially reducing patient costs. A novel tool at our institution provides direct costs for the identification of potential drivers.

OBJECTIVE

To assess perioperative healthcare costs for patients undergoing an ACDF.

METHODS

Patients who underwent an elective ACDF between July 2011 and January 2017 were identified retrospectively. Factors adding to total cost were placed into subcategories to identify the most significant contributors, and potential drivers of total cost were evaluated using a multivariable linear regression model.

RESULTS

A total of 465 patients (mean, age 53 ± 12 yr, 54% male) met the inclusion criteria for this study. The distribution of total cost was broken down into supplies/implants (39%), facility utilization (37%), physician fees (14%), pharmacy (7%), imaging (2%), and laboratory studies (1%). A multivariable linear regression analysis showed that total cost was significantly affected by the number of levels operated on, operating room time, and length of stay. Costs also showed a narrow distribution with few outliers and did not vary significantly over time.

CONCLUSION

These results suggest that facility utilization and supplies/implants are the predominant cost contributors, accounting for 76% of the total cost of ACDF procedures. Efforts at lowering costs within these categories should make the most impact on providing more cost-effective care.

Use of Patient Health Questionnaire-2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire-2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.

METHODS

Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.

RESULTS

Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.

CONCLUSIONS

A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

Quality of British and American Nationwide Quality of Care and Patient Safety Benchmarking Programs: Case Neurosurgery

BACKGROUND

Multiple nationwide outcome registries are utilized for quality benchmarking between institutions and individual surgeons.

OBJECTIVE

To evaluate whether nationwide quality of care programs in the United Kingdom and United States can measure differences in neurosurgical quality.

METHODS

This prospective observational study comprised 418 consecutive adult patients undergoing elective craniotomy at Helsinki University Hospital between December 7, 2011 and December 31, 2012.We recorded outcome event rates and categorized them according to British Neurosurgical National Audit Programme (NNAP), American National Surgical Quality Improvement Program (NSQIP), and American National Neurosurgery Quality and Outcomes Database (N2QOD) to assess the applicability of these programs for quality benchmarking and estimated sample sizes required for reliable quality comparisons.

RESULTS

The rate of in-hospital major and minor morbidity was 18.7% and 38.0%, respectively, and 30-d mortality rate was 2.4%. The NSQIP criteria identified 96.2% of major but only 38.4% of minor complications. N2QOD performed better, but almost one-fourth (23.2%) of all patients with adverse outcomes, mostly minor, went unnoticed. For NNAP, a sample size of over 4200 patients per surgeon is required to detect a 50.0% increase in mortality rates between surgeons. The sample size required for reliable comparisons between the rates of complications exceeds 600 patients per center per year.

CONCLUSION

The implemented benchmarking programs in the United Kingdom and United States fail to identify a considerable number of complications in a high-volume center. Health care policy makers should be cautious as outcome comparisons between most centers and individual surgeons are questionable if based on the programs.

Patient Demographic and Surgical Factors that Affect Completion of Patient-Reported Outcomes 90 Days and 1 Year After Spine Surgery: Analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC)

BACKGROUND

The Michigan Spine Surgery Improvement Collaborative is a statewide multicenter quality improvement registry. Because missing data can affect registry results, we used MSSIC to find demographic and surgical characteristics that affect the completion of patient-reported outcomes (PROs) at 90 days and 1 year.

METHODS

A total of 24,404 patients who had lumbar surgery (17,813 patients) or cervical surgery (6591 patients) were included. Multivariate logistic regression models of patient disease were constructed to identify risk factors for failure to complete scheduled PRO surveys.

RESULTS

Patients ≥65 years old and female patients were both more likely to respond at 90 days and 1 year. Increasing education was associated with greater response rate at 90 days and 1 year. Whites and African Americans had no differences in response rates. Calling provided the highest response rate at 90 days and 1 year. For cervical spine patients, only discharge to rehabilitation increased completion rates, at 90 days but not 1 year. For lumbar spine patients, spondylolisthesis or stenosis (vs. herniated disc) had a greater response rate at 1 year. Patients with leg (vs. back) pain had a greater response only at 1 year. Patients with multilevel surgery had an increased response at 1 year. Patients who underwent fusion were more likely to respond at 90 days, but not 1 year. Discharge to rehabilitation increased response at 90 days and 1 year.

CONCLUSIONS

A multivariate analysis from a multicenter prospective database identified surgical factors that affect PRO follow-up, up to 1 year. This information can be helpful for imputing missing PRO data and could be used to strengthen data derived from large prospective databases.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days

Objective

Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated.

Methods

Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay.

Results

In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay.

Discussion

DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus.

Implications for Practice

Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion

OBJECTIVE

With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.

METHODS

The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.

RESULTS

A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).

CONCLUSIONS

Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

Implementing a digital real-time Hydrocephalus and Shunt Registry to evaluate contemporary pattern of care and surgical outcome in pediatric hydrocephalus

OBJECTIVE

Treatment monitoring and outcome evaluation in pediatric hydrocephalus require gapless documentation regarding surgical and clinical follow-up data beginning from day 1 of treatment in order to apply high quality of care. Endoscopic procedures, shunt insertion and revision surgeries, and individual modifications of valve hardware or pressure settings during follow-up as well as established outcome measurements are highly relevant for complete illustration of the patient's hydrocephalus histories. A digital tool to capture, organize, and analyze comprehensive treatment-related data was estimated long overdue, consequentially developed, and implemented in daily pediatric neurosurgical routine.

METHODS

We established a self-contained, network-capable database application to supply and back up clinical information of complete surgical treatment history with implant status and follow up for all institutional pediatric hydrocephalus patients from 1995 to date. The application content has been prospectively complemented since 2012 during daily pediatric neurosurgical routine. Beside surgical data, neurological outcome and quality of life assessment were integrated according to validated scales to be recordable 2, 3, and 5 years after initial surgical intervention for prospective administration. The application is in continuous and problem-free use since implementation offering homogeneous and structured real-time information of surgical and corresponding neurological hydrocephalus-related data. By using an automatized data extraction tool, an exemplary surgical outcome evaluation reviewing institutional ventriculo-peritoneal shunt (VPS) treatment in infants over a period of more than 20 years was performed. To validate applicability, the Registry was successfully implemented in an external institution under identical conditions continuously serving for the same purpose until today.

RESULTS

Upon completion of the developing process, the application was successfully implemented into routine clinical workflow of our institution. In total, 579 pediatric hydrocephalus patients entered into the Registry with collectively 1874 corresponding hydrocephalus-related surgeries (9% neuro-endoscopic procedures, 18% temporary CSF-diversions, 73% shunt surgeries) so far. For exemplary surgical outcome analysis, the total volume of complex data sets could easily be reduced stepwise in regard to requested inclusion criteria. The selection process generated conclusive data of 256 institutional pediatric VPS patients providing a median follow-up of 8.5 years. Surgical outcome was evaluated in regard to hydrocephalus etiology, applied valve design, valve augmentation, cause of initial malfunction, time to initial shunt revision, and number of total revisions.

CONCLUSION

The pediatric hydrocephalus registry application delivers easy access to contemporary and up-to-date clinical information during daily clinical routine and proves comprehensive value for various scientific purposes. Institutional hydrocephalus etiologies, treatment modalities, and surgical outcome could be reviewed for a selected pediatric patient collective during an interval of more than 20 years and confirmed initial shunt treatment within the first year of age, communicating hydrocephalus and a history of prematurity as significant variables for unfavorable shunt survival and long-term revision rate. At our institution, the Registry emerged to an essential and sustainable tool to capture, organize, and analyze patterns of care in pediatric hydrocephalus patients of all etiologies and treatment modalities. Because of its adaptable and reliable predicate, a prospective multi-center utilization is currently in preparation.

Advances in Clinical Decision Support: Highlights of Practice and the Literature 2015-2016

Introduction: Advances in clinical decision support (CDS) continue to evolve to support the goals of clinicians, policymakers, patients and professional organizations to improve clinical practice, patient safety, and the quality of care. Objectives: Identify key thematic areas or foci in research and practice involving clinical decision support during the 2015-2016 time period. Methods: Thematic analysis consistent with a grounded theory approach was applied in a targeted review of journal publications, the proceedings of key scientific conferences as well as activities in standards development organizations in order to identify the key themes underlying work related to CDS. Results: Ten key thematic areas were identified, including: 1) an emphasis on knowledge representation, with a focus on clinical practice guidelines; 2) various aspects of precision medicine, including the use of sensor and genomic data as well as big data; 3) efforts in quality improvement; 4) innovative uses of computer-based provider order entry (CPOE) systems, including relevant data displays; 5) expansion of CDS in various clinical settings; 6) patient-directed CDS; 7) understanding the potential negative impact of CDS; 8) obtaining structured data to drive CDS interventions; 9) the use of diagnostic decision support; and 10) the development and use of standards for CDS. Conclusions: Active research and practice in 2015-2016 continue to underscore the importance and broad utility of CDS for effecting change and improving the quality and outcome of clinical care.

Predictors of extended length of stay, discharge to inpatient rehab, and hospital readmission following elective lumbar spine surgery: introduction of the Carolina-Semmes Grading Scale

OBJECTIVE Extended hospital length of stay (LOS), unplanned hospital readmission, and need for inpatient rehabilitation after elective spine surgery contribute significantly to the variation in surgical health care costs. As novel payment models shift the risk of cost overruns from payers to providers, understanding patient-level risk of LOS, readmission, and inpatient rehabilitation is critical. The authors set out to develop a grading scale that effectively stratifies risk of these costly events after elective surgery for degenerative lumbar pathologies. METHODS The Quality and Outcomes Database (QOD) registry prospectively enrolls patients undergoing surgery for degenerative lumbar spine disease. This registry was queried for patients who had undergone elective 1- to 3-level lumbar surgery for degenerative spine pathology. The association between preoperative patient variables and extended postoperative hospital LOS (LOS ≥ 7 days), discharge status (inpatient facility vs home), and 90-day hospital readmission was assessed using stepwise multivariate logistic regression. The Carolina-Semmes grading scale was constructed using the independent predictors for LOS (0-12 points), discharge to inpatient facility (0-18 points), and 90-day readmission (0-6 points), and its performance was assessed using the QOD data set. The performance of the grading scale was then confirmed separately after using it in 2 separate neurosurgery practice sites (Carolina Neurosurgery & Spine Associates [CNSA] and Semmes Murphey Clinic). RESULTS A total of 6921 patients were analyzed. Overall, 290 (4.2%) patients required extended LOS, 654 (9.4%) required inpatient facility care/rehabilitation on hospital discharge, and 474 (6.8%) were readmitted to the hospital within 90 days postdischarge. Variables that remained as independently associated with these unplanned events in multivariate analysis included age ≥ 70 years, American Society of Anesthesiologists Physical Classification System class > III, Oswestry Disability Index score ≥ 70, diabetes, Medicare/Medicaid, nonindependent ambulation, and fusion. Increasing point totals in the Carolina-Semmes scale effectively stratified the incidence of extended LOS, discharge to facility, and readmission in a stepwise fashion in both the aggregate QOD data set and when subsequently applied to the CNSA/Semmes Murphey practice groups. CONCLUSIONS The authors introduce the Carolina-Semmes grading scale that effectively stratifies the risk of prolonged hospital stay, need for postdischarge inpatient facility care, and 90-day hospital readmission for patients undergoing first-time elective 1- to 3-level degenerative lumbar spine surgery. This grading scale may be helpful in identifying patients who may require additional resource utilization within a global period after surgery.

Do Health Information Exchanges Deter Repetition of Medical Services?

Repetition of medical services by providers is one of the major sources of healthcare costs. The lack of access to previous medical information on a patient at the point of care often leads a physician to perform medical procedures that have already been done. Multiple healthcare initiatives and legislation at both the federal and state levels have mandated Health Information Exchange (HIE) systems to address this problem. This study aims to assess the extent to which HIE could reduce these repetitions, using data from Centers for Medicare 8 Medicaid Services and a regional HIE organization. A 2-Stage Least Square model is developed to predict the impact of HIE on repetitions of two classes of procedures: diagnostic and therapeutic. The first stage is a predictive analytic model that estimates the duration of tenure of each HIE member-practice. Based on these estimates, the second stage predicts the effect of providers’ HIE tenure on their repetition of medical services. The model incorporates moderating effects of a federal quality assurance program and the complexity of medical procedures with a set of control variables. Our analyses show that a practice's tenure with HIE significantly lowers the repetition of therapeutic medical procedures, while diagnostic procedures are not impacted. The medical reasons for the effects observed in each class of procedures are discussed. The results will inform healthcare policymakers and provide insights on the business models of HIE platforms.

Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy: An Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015

In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume. The first pathway, MIPS, consolidates several Medicare quality-reporting programs into one composite score that will be derived by four performance categories, including quality (30%), resource utilization (30%), meaningful use (25%), and clinical practice improvement activities (15%). The APM pathway includes the following programs: Medicare accountable care organizations as part of the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Comprehensive Primary Care initiative. Existing APMs have yet to be determined as eligible. We provide a contextual framework of the healthcare legislation that has led to the formation of current health policy and offer recommendations regarding SGR how orthopaedic surgeons may best steer through such reimbursement models.