1
|
Vorster PA, Burger R, Mann TN, Nkonki LL, Reuter H, Davis JH. Surgeon variation: a south african spinal pathology treatment survey. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08295-6. [PMID: 38769162 DOI: 10.1007/s00586-024-08295-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE To investigate variation in treatment decisions among spine surgeons in South Africa and the association between surgeon characteristics and the treatment they select. METHODS We surveyed 79 South African spine surgeons. We presented four vignettes (cervical spine distractive flexion injury, lumbar disc herniation, degenerative spondylolisthesis with stenosis, and insufficiency fracture) for them to assess and select treatments. We calculated the index of qualitative variation (IQV) to determine the degree of variability within each vignette. We used Fisher's exact, and Kruskal-Wallis tests to assess the relationships between surgeons' characteristics and their responses per vignette. We compared their responses to the recommendations of a panel of spine specialists. RESULTS IQVs showed moderate to high variability for cervical spine distractive flexion injury and insufficiency fracture and slightly lower levels of variability for lumbar disc herniation and degenerative spondylolisthesis with stenosis. This confirms the heterogeneity in South African spine surgeons' management of spinal pathologies. The surgeon characteristics associated with their treatment selection that were important were caseload, experience and training, and external funding. Also, 19% of the surgeons selected a treatment option that the Panel did not support. CONCLUSION The findings make a case for evaluating patient outcomes and costs to identify value-based care. Such research would help countries that are seeking to contract with providers on value. Greater uniformity in treatment and easily accessible outcomes reporting would provide guidance for patients. Further investment in training and participation in fellowship programs may be necessary, along with greater dissemination of information from the literature.
Collapse
Affiliation(s)
- Pamela A Vorster
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa.
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Stellenbosch, South Africa
| | - Theresa N Mann
- Division of Orthopedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Institute of Orthopedics and Rheumatology, Mediclinic Winelands Orthopedic Hospital, Stellenbosch, South Africa
| | - Lungiswa L Nkonki
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helmuth Reuter
- Institute of Orthopedics and Rheumatology, Mediclinic Winelands Orthopedic Hospital, Stellenbosch, South Africa
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Johan H Davis
- Division of Orthopedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Institute of Orthopedics and Rheumatology, Mediclinic Winelands Orthopedic Hospital, Stellenbosch, South Africa
| |
Collapse
|
2
|
Kuruba V, Cherukuri AMK, Arul S, Alzarooni A, Biju S, Hassan T, Gupta R, Alasaadi S, Sikto JT, Muppuri AC, Siddiqui HF. Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders. Cureus 2023; 15:e45962. [PMID: 37900519 PMCID: PMC10600402 DOI: 10.7759/cureus.45962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.
Collapse
Affiliation(s)
- Venkataramana Kuruba
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Vijayawada, IND
| | | | - Subiksha Arul
- Department of Medicine, JONELTA Foundation School of Medicine, University of Perpetual Help System DALTA, Manila, PHL
| | | | - Sheryl Biju
- Department of Medicine, Christian Medical College, Vellore, IND
| | - Taimur Hassan
- Department of Medicine, Texas A&M College of Medicine, College Station, USA
| | - Riya Gupta
- Department of Medicine, Shri Atal Bihari Vajpayee Medical College and Research Institute, Bangalore, IND
| | - Saya Alasaadi
- Department of Medicine, University College of Dublin, Dublin, IRL
| | - Jarin Tasnim Sikto
- Department of Medicine, Jahurul Islam Medical College and Hospital, Bhagalpur, BGD
| | - Arnav C Muppuri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Humza F Siddiqui
- Department of Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
| |
Collapse
|
3
|
Lubelski D, Feghali J, Hersh A, Kopparapu S, Al-Mistarehi AH, Belzberg AJ. Differences in the surgical treatment of adult and pediatric brachial plexus injuries among peripheral nerve surgeons. Clin Neurol Neurosurg 2023; 228:107686. [PMID: 36963285 DOI: 10.1016/j.clineuro.2023.107686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES Peripheral nerve surgeons disagree on the optimal timing and treatment of brachial plexus injuries (BPI). This study aims to survey peripheral nerve surgeons on their management of BPI, including disagreement. METHODS Surgeons responded to a case-based survey involving traumatic and birth injuries leading to BPI involving the upper and lower trunks, and pre- and post-ganglionic injuries. RESULTS Out of 255 invited surgeons, 154 participated, with specialties of Neurosurgery (33.7%), Plastic surgery (32.5%), and Orthopedics (32.5%). For the adult C5-6 avulsion injury, 97.4% agreed they would operate. There was 46.2% disagreement regarding the pediatric upper trunk neuroma-in-continuity case, and similar disagreement (50.0%) was recorded on exploring the brachial plexus for a pediatric lower trunk injury case. High percentages of surgeons were more likely to explore the plexus, such as at upper BPI. Also, most participants reported nerve transfer for the upper and lower trunk avulsion injuries, but there was 55.6% disagreement regarding nerve transfer for the infant with the upper trunk neuroma-in-continuity. Among those elected to perform nerve transfer, most (70.0%-84.5%) would perform an accessory-to-suprascapular nerve transfer for upper BPI, while brachialis-to-anterior interosseous and supinator branch of the radial nerve-to-posterior interosseous were preferred for lower BPI (30.0%-55.9%). CONCLUSIONS Substantial disagreement exists among peripheral nerve surgeons in managing adult and pediatric BPI. In adult BPI, most prefer to operate at the time of the presentation and perform extensive nerve transfers. The accessory-suprascapular transfer was recommended for upper BPI, while brachialis and radial nerves were preferred for lower BPI. The most significant disagreements exist in operation and nerve transfer for pediatric upper BPI and brachial plexus explorations. Geography, specialty, and operative volume contribute to the differences seen.
Collapse
Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Andrew Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | | | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| |
Collapse
|
4
|
Clinicians' perceptions around discectomy surgery for lumbar disc herniation: a survey of orthopaedic and neuro-surgeons in Australia and New Zealand. Arch Orthop Trauma Surg 2023; 143:189-201. [PMID: 34216261 DOI: 10.1007/s00402-021-04019-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Understanding practice-based differences in treatment of lumbar disc herniations (LDHs) is vital for reducing unwarranted variation in the delivery of spine surgical health care. Identifying factors that influence surgeons' decision-making will offer useful insights for developing the most cost-effective and safest surgical strategy as well as developing surgeon education materials for common lumbar pathologies. This study was to capture any variation in techniques used by surgeons in Australia and New Zealand (ANZ) region, and perceived complications of different surgical procedures for primary and recurrent LDH (rLDH). MATERIALS AND METHODS Web-based survey study was emailed to orthopaedic and neurosurgeons who routinely performed spinal surgery in ANZ from Decmber 20, 2018 to February 20, 2020. The response data were analyzed to assess for differences based on geography, practice setting, speciality, practice experience, practice length, and operative volume. RESULTS Invitations were sent to 150 surgeons; 96 (64%) responded. Most surgeons reported microdiscectomy as their surgical technique of choice for primary LDH (73%) and the first rLDH (72%). For the second rLDH, the preferred choice for most surgeons was fusion surgery (82%). A surgeon's practice setting (academic/private/hybrid) was a statistically significant factor in what surgical procedure was chosen for the first rLDH (P = 0.014). When stratifying based on surgeon experience, there were statisfically significant differences based on the annual volume of spine surgeries performed (perceived reherniation rates following primary discectomy, P = 0.013; perceived reherniation rates following revision surgeries, P = 0.017; perceived intraoperative complications rates following revision surgeries, P = 0.016) and based on the annual volume of lumbar discectomies performed (perceived reherniation rates following revision surgeries, P = 0.022; perceived intraoperative complications rates following revision surgeries, P = 0.036; perceived durotomy rates following primary discectomy, P = 0.023). CONCLUSIONS Surgeons' annual practice volume and practice setting have significant influences in the selection of surgical procedures and the perception of surgical complications when treating LDHs.
Collapse
|
5
|
Wilton A. Risk Factors for Postoperative Complications and In-Hospital Mortality Following Surgery for Cervical Spinal Cord Injury. Cureus 2022; 14:e31960. [DOI: 10.7759/cureus.31960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 11/29/2022] Open
|
6
|
Alnaami I, Alawashiz S, Algahtany M. Differences in the Practice of Traumatic Spinal Cord Injury Management Among Spine Surgeons in Saudi Arabia. Int J Spine Surg 2022; 16:881-889. [PMID: 36302603 PMCID: PMC9926642 DOI: 10.14444/8340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study aims to explore the ease of adopting clinical practice guidelines (CPGs) in managing traumatic spinal cord injury (TSCI) among spine surgeons, with particular focus on the use of steroids, high-dependency unit, early spinal cord decompression, and maintaining a target mean arterial blood pressure (MAP). METHODS We conducted a cross-sectional study among the practicing spinal surgeons in Saudi Arabia and included surgeons from neurosurgical and orthopedic backgrounds. The study period was from April to June 2020. The respondents provided sociodemographic data, training background, years of experience, and their clinical practices in managing TSCI via a survey tool constructed based on a literature review. The data were analyzed to evaluate the association between a surgeon's demographics and clinical practices. RESULTS Ninety-eight spinal surgeons responded, comprising 40% of the practicing spine surgeon population in Saudi Arabia. The only area where the neurosurgical spine and orthopedic spine surgeons' practices differed significantly was maintaining MAP within a target range. Other differences between practices were not statistically significant. The authors also found a significant correlation between the surgeon's school of training and their experience concerning steroids administration. On the other hand, the surgeon experience and volume of treated TSCI cases correlated significantly with admission to a high-dependency unit. CONCLUSIONS The adoption of CPGs remains a challenge to many spinal surgeons. Neurosurgeons are more into keeping the MAP at certain target, whereas the school of training and surgeon experience were the largest determinants of the surgeon's practice in managing TSCI in Saudi Arabia. CLINICAL RELEVANCE As the variability in managment among spine surgeons remains a challenge, international and national spine societies are expected to build clinical practice guidelines from the limited existing literature. LEVEL OF EVIDENCE: 3
Collapse
Affiliation(s)
- Ibrahim Alnaami
- Division of Neurosurgery, Department of Surgery, King Khalid University, Abha, Saudi Arabia .,Department of Pediatric Neurosurgery, Abha Maternity and Children Hospital, Abha, Saudi Arabia.,Department of Neurosurgery, Aseer Central Hospital, Abha, Saudi Arabia
| | - Salman Alawashiz
- Department of Pediatric Orthopaedics, Abha Maternity and Children Hospital, Abha, Saudi Arabia
| | - Mubarak Algahtany
- Division of Neurosurgery, Department of Surgery, King Khalid University, Abha, Saudi Arabia,Department of Neurosurgery, Aseer Central Hospital, Abha, Saudi Arabia
| |
Collapse
|
7
|
Practice Variation Between Salaried and Fee-for-Service Surgeons for Lumbar Surgery. Can J Neurol Sci 2022:1-8. [PMID: 35705195 DOI: 10.1017/cjn.2022.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
8
|
Weir TB, Usmani MF, Camacho J, Sokolow M, Bruckner J, Jazini E, Jauregui JJ, Gopinath R, Sansur C, Davis R, Koh EY, Banagan KE, Gelb DE, Buraimoh K, Ludwig SC. Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2021; 15:701-709. [PMID: 34266936 DOI: 10.14444/8092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - M Farooq Usmani
- Department of General Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jael Camacho
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sokolow
- Quality Management Division, University of Maryland Medical System, Baltimore, Maryland
| | - Jacob Bruckner
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Julio J Jauregui
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rohan Gopinath
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randy Davis
- Department of Orthopaedics, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland
| | - Eugene Y Koh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kelley E Banagan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel E Gelb
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kendall Buraimoh
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven C Ludwig
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
9
|
Myers M, Hall S, Sadek AR, Dare C, Griffith C, Shenouda E, Nader-Sepahi A. Differences in management of isolated spinal fractures between neurosurgery and orthopaedics: a 6-year retrospective study. Br J Neurosurg 2020; 35:68-72. [PMID: 32441143 DOI: 10.1080/02688697.2020.1763256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The acute management of spinal fractures is traditionally split between neurosurgeons and orthopaedic surgeons and the specialities have varying approaches to management. This study investigates differences between neurosurgeons and spinal orthopaedic surgeons in the management of spinal fractures at a single trauma centre in the United Kingdom. METHODS A retrospective study at a single trauma centre of patients identified using the Trauma Audit and Research Network (TARN). Case notes and radiological investigations were reviewed for demographics, fracture classification, clinical management and outcomes. Polytrauma cases and patients managed by non-neurosurgical/orthopaedic specialties were excluded. RESULTS A total of 465 patients were included in this study (neurosurgery n = 266, orthopaedics n = 199). There were no significant differences between groups for age, gender, Charlson co-morbidity score or distribution of fractures using the AO spine classification. Patients admitted and managed under the orthopaedic surgeons were more likely to undergo a surgical procedure when compared to those admitted under the neurosurgeons (n = 71; 35.7% vs n = 71; 26.8%, p = 0.042, OR 1.56 95%CI 1.056 to 2.31). The median overall length of stay was 8 days and there was no significant difference between teams; however, the neurosurgical cohort were more likely to be admitted to an intensive care unit (24.3% vs 16.2%, p = 0.04). CONCLUSION This study is the first in the United Kingdom to compare neurosurgical and orthopaedic teams in their management of spinal fractures. It demonstrates that differences may exist both in operating rates and outcomes.
Collapse
Affiliation(s)
- Matthew Myers
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Samuel Hall
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Ahmed-Ramadan Sadek
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Christopher Dare
- Department of Trauma and Orthopaediacs, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Colin Griffith
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Emad Shenouda
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| | - Ali Nader-Sepahi
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom of Great Britain and Northern Ireland.,Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
10
|
Orthopaedics and neurosurgery: Is there a difference in surgical outcomes following anterior cervical spinal fusion? J Orthop 2020; 21:278-282. [PMID: 32508432 DOI: 10.1016/j.jor.2020.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 11/21/2022] Open
Abstract
Objective The superiority of neurosurgical over orthopaedic spinal procedures is a point of contention. While there is the perception that neurosurgeons are more specifically trained to deal with spinal pathology, no study has directly compared outcomes of spinal surgeries performed by both groups. Methods We sought to evaluate the differences in length of surgery, hospital stay, complications, mortality, and readmission for anterior cervical decompression and fusion (ACDF) performed by neurosurgeons versus orthopaedic surgeons. Results 17,967 ACDF procedures were analyzed. Neurosurgeons performed 74.3% of the fusions with a trend towards longer operative times and significantly more patients that were discharged to extended care facilities. There was no significant difference in the length of stay, overall complications, mortality, readmission, or reoperation when comparing the two specialties. Conclusion Despite a significantly higher volume of ACDF performed by neurosurgeons, outcomes are comparable following orthopaedic and neurosurgical procedures.
Collapse
|
11
|
Kumaria A, Bateman AH, Eames N, Fehlings MG, Goldstein C, Meyer B, Paquette SJ, Yee AJM. Advancing spinal fellowship training: an international multi-centre educational perspective. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2437-2443. [PMID: 31407164 DOI: 10.1007/s00586-019-06098-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery. METHODS Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training. RESULTS Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training. CONCLUSIONS Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.
Collapse
Affiliation(s)
- Ashwin Kumaria
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Antony H Bateman
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Niall Eames
- Belfast Health and Social Care Trust, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - Christina Goldstein
- Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65212, USA
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | | | - Albert J M Yee
- Department of Surgery, University of Toronto, Toronto, Canada
- University of Toronto Spine Program, Toronto, Canada
- Marvin Tile Chair, Division Head of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Rm MG 371-B, Toronto, ON, M4N 3M5, Canada
| |
Collapse
|
12
|
Jung JM, Lee SU, Hyun SJ, Kim KJ, Jahng TA, Oh CW, Kim HJ. Trends in Incidence and Treatment of Herniated Lumbar Disc in Republic of Korea : A Nationwide Database Study. J Korean Neurosurg Soc 2019; 63:108-118. [PMID: 31408926 PMCID: PMC6952735 DOI: 10.3340/jkns.2019.0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/31/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to determine the incidence and analyze trends of the herniated lumbar disc (HLD) based on a national database in the Republic of Korea (ROK) from January 2008 to December 2016. METHODS This study was a retrospective analysis of data obtained from the national health-claim database provided by the National Health Insurance Service for 2008-2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of HLD were calculated, and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and some treatments were analyzed using the Korean Classification of Diseases procedure codes. RESULTS The number of patients diagnosed with HLD was 472245 in 2008 and increased to 537577 in 2012; however, it decreased to 478697 in 2016. The pattern of crude incidence and the standardized incidence were also similar. Overall, the incidence of HLD increased annually for the 30s, 40s, 50s, and 70s until 2012 and then decreased. However, the incidence of HLD for the 80s continued to increase. The crude incidence of HLD in female patients exceeded that of male patients in their middle age (30s or 40s) and was 1.5-1.6 times higher than in male patients in their 60s. The total number of open discectomy (OD) increased from 71598 in 2008 to 93942 in 2012 and then decreased to 85846 in 2016. The rate of younger patients (the 20s, 30s, and 40s) who underwent OD was decreased, and the rate of younger patients who underwent percutaneous endoscopic lumbar discectomy was increased. However, the rate of older patients (the 70s and 80s) who underwent OD was continuously increased. CONCLUSION This nationwide data on HLD from 2008 to 2016 in the ROK demonstrated that the crude incidence and the standardized incidence increased until 2012 and then decreased. The annual crude incidence was different according to age and sex. These findings may be considered when deciding future health policy, especially in countries with a similar national health insurance system (or with plans to adopt).
Collapse
Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
13
|
Abstract
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.
Collapse
|
14
|
Assessing Variability in In-Hospital Complication Rates Between Surgical Services for Patients Undergoing Posterior Cervical Decompression and Fusion. Spine (Phila Pa 1976) 2019; 44:163-168. [PMID: 30005039 DOI: 10.1097/brs.0000000000002780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study was performed including all patients who underwent posterior cervical decompression and fusion (PCDF) by an orthopedic or neurological surgeon at a single institution between January 1, 2006 and November 30, 2016, and all patients who underwent PCDF by a spine surgeon in the National Surgical Quality Improvement Project database between 2007 and 2015. In-hospital complications were compared between surgical specialties. OBJECTIVE The goal of this study was to determine if in-hospital complication rates differ significantly between surgical services for PCDF patients. SUMMARY OF BACKGROUND DATA Orthopedic and neurological surgeons commonly perform PCDF, and differences in surgical opinion and management have been cited between these two specialties in recent literature. This represents a variable that should be evaluated. METHODS Cases were preliminarily identified by CPT code and confirmed using the ICD-9 code 81.03 or ICD-10 code M43.22. Cases were separated based on if the primary surgeon was an orthopedic surgeon or a neurological surgeon. The primary outcome variable was in-hospital complication rates; cohorts were compared using bivariate and multivariate analysis. RESULTS A total of 1221 patients at a single institution and 11,116 patients within the National Surgical Quality Improvement Project database underwent PCDF. Patients in the orthopedic surgery service had a higher proportion of bleeding requiring transfusion in both the institutional sample (14.5% vs. 9.08%, P = 0.003) and national sample (11.16% vs. 6.18%, P < 0.0001). In the national sample, orthopedic surgeons were 1.66 times as likely to encounter an in-hospital complication than neurological surgeons (95% CI: 1.44-1.91, P < 0.0001). CONCLUSION When examining a large institutional sample and an even larger national sample, this study found that orthopedic surgeons were more likely to encounter perioperative bleeding requiring transfusion than neurological surgeons. When in-hospital complications were considered as a whole, in the national sample, orthopedic surgeons are more likely to encounter in-hospital complications than neurological surgeons when performing PCDF. LEVEL OF EVIDENCE 3.
Collapse
|
15
|
Alvin MD, Lubelski D, Alam R, Williams SK, Obuchowski NA, Steinmetz MP, Wang JC, Melillo AJ, Pahwa A, Benzel EC, Modic MT, Quencer R, Mroz TE. Spine Surgeon Treatment Variability: The Impact on Costs. Global Spine J 2018; 8:498-506. [PMID: 30258756 PMCID: PMC6149049 DOI: 10.1177/2192568217739610] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Cross-sectional analysis. OBJECTIVES Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. METHODS Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. RESULTS For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. CONCLUSIONS Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.
Collapse
Affiliation(s)
- Matthew D. Alvin
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, MD,
USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD,
USA
| | - Ridwan Alam
- The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Seth K. Williams
- University of Wisconsin Department of Orthopedics and Rehabilitation,
Madison, WI, USA
| | | | - Michael P. Steinmetz
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | | | - Alfred J. Melillo
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Amit Pahwa
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Edward C. Benzel
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Michael T. Modic
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA
| | - Robert Quencer
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Thomas E. Mroz
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA,Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH,
USA,Thomas E. Mroz, Neurological Institute, Cleveland
Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, The
Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA.
| |
Collapse
|
16
|
Sollmann N, Morandell C, Albers L, Behr M, Preuss A, Dinkel A, Meyer B, Krieg SM. Association of decision-making in spinal surgery with specialty and emotional involvement-the Indications in Spinal Surgery (INDIANA) survey. Acta Neurochir (Wien) 2018; 160:425-438. [PMID: 29322267 DOI: 10.1007/s00701-017-3459-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/28/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although recent trials provided level I evidence for the most common degenerative lumbar spinal disorders, treatment still varies widely. Thus, the Indications in Spinal Surgery (INDIANA) survey explores whether decision-making is influenced by specialty or personal emotional involvement of the treating specialist. METHOD Nationwide, neurosurgeons and orthopedic surgeons specialized in spine surgery were asked to answer an Internet-based questionnaire with typical clinical patient cases of lumbar disc herniation (DH), lumbar spinal stenosis (SS), and lumbar degenerative spondylolisthesis (SL). The surgeons were assigned to counsel a patient or a close relative, thus creating emotional involvement. This was achieved by randomly allocating the surgeons to a patient group (PG) and relative group (RG). We then compared neurosurgeons to orthopedic surgeons and the PG to the RG regarding treatment decision-making. RESULTS One hundred twenty-two spine surgeons completed the questionnaire (response rate 78.7%). Regarding DH and SS, more conservative treatment among orthopedic surgeons was shown (DH: odds ratio [OR] 4.1, 95% confidence interval [CI] 1.7-9.7, p = 0.001; SS: OR 3.9, CI 1.8-8.2, p < 0.001). However, emotional involvement (PG vs. RG) did not affect these results for any of the three cases (DH: p = 0.213; SS: p = 0.097; SL: p = 0.924). CONCLUSIONS The high response rate indicates how important the issues raised by this study actually are for dedicated spine surgeons. Moreover, there are considerable variations in decision-making for the most common degenerative lumbar spinal disorders, although there is high-quality data from large multicenter trials available. Emotional involvement, though, did not influence treatment recommendations.
Collapse
Affiliation(s)
- Nico Sollmann
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
| | - Carmen Morandell
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lucia Albers
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
- Institute of Social Pediatrics and Adolescents Medicine, Ludwig-Maximilians-Universität München, Haydnstr. 5, 80336 Munich, Germany
| | - Michael Behr
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Alexander Preuss
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andreas Dinkel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| |
Collapse
|
17
|
Sabesan VJ, Petersen-Fitts GR, Ramthun KW, Brand JP, Stine SA, Whaley JD. Strategies to Contain Cost Associated with Orthopaedic Care. JBJS Rev 2018; 6:e3. [PMID: 29461988 DOI: 10.2106/jbjs.rvw.17.00040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vani J Sabesan
- Cleveland Clinic Florida, Weston, Florida.,Wayne State University School of Medicine, Detroit, Michigan
| | | | - Kyle W Ramthun
- Wayne State University School of Medicine, Detroit, Michigan
| | - Jordan P Brand
- Wayne State University School of Medicine, Detroit, Michigan
| | - Sasha A Stine
- Wayne State University School of Medicine, Detroit, Michigan
| | - James D Whaley
- Wayne State University School of Medicine, Detroit, Michigan
| |
Collapse
|
18
|
Spinal Surgeon Variation in Single-Level Cervical Fusion Procedures: A Cost and Hospital Resource Utilization Analysis. Spine (Phila Pa 1976) 2017; 42:1031-1038. [PMID: 27779602 DOI: 10.1097/brs.0000000000001962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
Collapse
|
19
|
Zygourakis CC, Valencia V, Boscardin C, Nayak RU, Moriates C, Gonzales R, Theodosopoulos P, Lawton MT. Predictors of Variation in Neurosurgical Supply Costs and Outcomes Across 4904 Surgeries at a Single Institution. World Neurosurg 2016; 96:177-183. [PMID: 27613498 DOI: 10.1016/j.wneu.2016.08.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/27/2016] [Accepted: 08/30/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is high variability in neurosurgical costs, and surgical supplies constitute a significant portion of cost. Anecdotally, surgeons use different supplies for various reasons, but there is little understanding of how supply choices affect outcomes. Our goal is to evaluate the effect of patient, procedural, and provider factors on supply cost and to determine if supply cost is associated with patient outcomes. METHODS We obtained patient information (age, gender, payor, case mix index [CMI], body mass index, admission source), procedural data (procedure type, length, date), provider information (name, case volume), and total surgical supply cost for all inpatient neurosurgical procedures from 2013 to 2014 at our institution (n = 4904). We created mixed-effect models to examine the effect of each factor on surgical supply cost, 30-day readmission, and 30-day mortality. RESULTS There was significant variation in surgical supply cost between and within procedure types. Older age, female gender, higher CMI, routine/elective admission, longer procedure, and larger surgeon volume were associated with higher surgical supply costs (P < 0.05). Routine/elective admission and higher surgeon volume were associated with lower readmission rates (odds ratio, 0.707, 0.998; P < 0.01). Only patient factors of older age, male gender, private insurance, higher CMI, and emergency admission were associated with higher mortality (odds ratio, 1.029, 1.700, 1.692, 1.080, 2.809). There was no association between surgical supply cost and readmission or mortality (P = 0.307, 0.548). CONCLUSIONS A combination of patient, procedural, and provider factors underlie the significant variation in neurosurgical supply costs at our institution. Surgical supply costs are not correlated with 30-day readmission or mortality.
Collapse
Affiliation(s)
- Corinna C Zygourakis
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA.
| | - Victoria Valencia
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Christy Boscardin
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rahul U Nayak
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA
| | - Christopher Moriates
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Ralph Gonzales
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Continuous Process Improvement Department, UCSF Health, San Francisco, California, USA
| | - Philip Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
20
|
Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States. Spine (Phila Pa 1976) 2016; 41:978-986. [PMID: 26679881 DOI: 10.1097/brs.0000000000001396] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Electronic survey. OBJECTIVE To identify the surgical treatment patterns for low back pain (LBP), among U.S. spine surgeons. Specifically determine (1) differences in surgical treatment responses based on various demographic variables; (2) probability of disagreement based on surgeon subgroups. SUMMARY OF BACKGROUND DATA Multiple surgical and nonsurgical treatments exist for LBP. Without strong evidence or clear guidelines for the indications and optimal treatments, there is substantial variability in surgical treatments used. METHODS A total of 445 U.S. spine surgeons completed a survey of clinical and radiographic case scenarios on patients with mechanical LBP, no leg pain, and concordant discograms. Surgical treatment options included no surgery, anterior lumbar interbody fusion (ALIF), posterolateral fusion with pedicle screws, transforaminal/posterior lumbar interbody fusion (TLIF/PLIF), etc. Statistical significance was set at 0.01 to account for multiple comparisons. RESULTS There was substantial clinical equipoise (∼75% disagreement) among surgeons on the approach to treat patients with LBP. Disagreement was highest in the southwest and lowest in the Midwest (82% vs. 69%, respectively); there was significantly lower disagreement among those in academic practices versus those in private/hybrid practices (56% vs.79%, respectively). Those in academic practices had approximately four times greater odds of choosing no surgery as compared to those in hybrid and private practices, who were more likely to choose ALIF or PLIF/TLIF. Those with fellowship training had approximately two times greater odds of selecting no surgery and four times greater odds of selecting ALIF as compared to those without fellowship training who were more likely to select TLIF/PLIF. CONCLUSION Significant differences exist among U.S. spine surgeons in the treatment of LBP. These differences stem from geographical location of the practice, specialty, practice type, and fellowship training. Recognizing the substantial variability underlies the importance of additional studies aimed at identifying the proper indications and most cost-effective treatments for LBP. LEVEL OF EVIDENCE 3.
Collapse
|
21
|
Mroz TE, Lubelski D, Williams SK, O'Rourke C, Obuchowski NA, Wang JC, Steinmetz MP, Melillo AJ, Benzel EC, Modic MT, Quencer RM. Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. Spine J 2014; 14:2334-43. [PMID: 24462813 DOI: 10.1016/j.spinee.2014.01.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 11/29/2013] [Accepted: 01/17/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States. PURPOSE To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation. STUDY DESIGN Electronic survey. PATIENT SAMPLE An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States. OUTCOME MEASURES The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups. METHODS A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons. RESULTS Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume. CONCLUSIONS Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system.
Collapse
Affiliation(s)
- Thomas E Mroz
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA.
| | - Daniel Lubelski
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Seth K Williams
- University of Miami Miller School of Medicine, Department of Orthopaedic Surgery (SKW) and Department of Radiology (RQ) , 1400 Nw 10th Ave Ste 509, Miami, FL 33124, USA
| | - Colin O'Rourke
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Nancy A Obuchowski
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Jeffrey C Wang
- University of California, Department of Orthopaedic Surgery, 1245 16th St #220, Santa Monica, CA 90404, USA
| | - Michael P Steinmetz
- MetroHealth Medical Center, Case School of Medicine, 2500 Metrohealth Dr, Cleveland, OH 44109, USA
| | - Alfred J Melillo
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Edward C Benzel
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Michael T Modic
- Cleveland Clinic Foundation, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA
| | - Robert M Quencer
- University of Miami Miller School of Medicine, Department of Orthopaedic Surgery (SKW) and Department of Radiology (RQ) , 1400 Nw 10th Ave Ste 509, Miami, FL 33124, USA
| |
Collapse
|
22
|
Abstract
STUDY DESIGN Retrospective review on prospective cohort and explicit chart review. OBJECTIVE To identify early spine trauma predictors of functional disability and to assess management compliance to established spine trauma treatment algorithms. SUMMARY OF BACKGROUND DATA Identification of early (within 48 hours) spine trauma predictors of functional disability is novel and may assist in the management of patients with trauma. Also, with significant global variation, spine trauma treatment algorithms are essential. METHODS Analysis was performed on patients with spine trauma from May 1, 2009, to January 1, 2011. Functional outcomes were determined using the Glasgow Outcome Scale (GOS) at 1 year. Univariate and multivariate regressions were applied to investigate the effects of the injury severity score, age, blood sugar level, vital signs, traumatic brain injury, comorbidities, coagulation profile, neurology, and spine injury characteristics. A compliance study was performed using the SLIC and TLICS spine trauma algorithms. RESULTS The completion rate for the GOS was 58.8%. The completed GOS cohort was 4.2 years younger in terms of mean age, had more number of patients with severe polytrauma, but less number of patients with severe spinal cord injuries (ASIA [American Spinal Injury Association] A, B, and C) in comparison with the uncompleted GOS cohort. Multivariate logistic regression revealed 3 independent early spine trauma predictors of functional disability with statistical significance (P < 0.05). They were (1) hypotension (OR [odds ratio] = 1.98; CI [confidence interval] = 1.13-3.49), (2) hyperglycemia (OR = 1.67; CI = 1.09-2.56), and (3) moderate/severe traumatic brain injury (OR = 5.88; CI = 1.71-20.16). There were 305 patients with subaxial cervical spine injuries and 653 patients with thoracolumbar spine injuries. The subaxial cervical spine injury classification and thoracolumbar injury classification and severity score compliance studies returned agreements of 96.1% and 98.9%, respectively. CONCLUSION Early independent spine trauma predictors of functional disability identified in a level 1 trauma center with high compliance to the subaxial cervical spine injury classification and thoracolumbar injury classification and severity score algorithms were hypotension, hyperglycemia, and moderate or severe traumatic brain injury. Spine trauma injury variables alone were shown not to be predictive of functional disability. LEVEL OF EVIDENCE 3.
Collapse
|