Hospital and Surgeon Variation in Patient-reported Functional Outcomes After Lumbar Spine Fusion

Abstract

Study Design. Statewide retrospective cohort study using prospectively collected data from the Spine Care and Outcomes Assessment Program, capturing ∼75% of the state's spine fusion procedures. Objective. The aim of this study was to estimate the variation in patient-reported outcomes (PROs) 1 year after elective lumbar fusion surgery across surgeons and hospitals; and to discuss the potential impact of guiding patient selection using a PRO prediction tool. Summary of Background Data. Despite an increasing interest in incorporating PROs as part of the move toward value-based payment and to improve quality, limited evidence exists on how PROs vary across hospitals and surgeons, a key aspect of using these metrics for quality profiling. Methods. We examined patient-reported functional improvement (≥15-point reduction in the Oswestry Disability Index [ODI]) and minimal disability (reaching ≤22 on the ODI) 1 year after surgery in 17 hospitals and 58 surgeons between 2012 and 2017. Outcomes were risk-adjusted for patient characteristics with multiple logistic regressions and reliability-adjusted using hierarchical models. Results. Of the 737 patients who underwent lumbar fusion (mean [SD] age, 63 [12] years; 60% female; 84% had stenosis; 70% had spondylolisthesis), 58.7% achieved functional improvement and 42.5% reached minimal disability status at 1 year. After adjusting for patient factors, there was little variation between hospitals and surgeons (maximum interclass correlation was 3.5%), and this variation became statistically insignificant after further reliability adjustment. Avoiding operation on patients with <50% chance of functional improvement may reduce current surgical volume by 63%. Conclusion. Variations in PROs across hospitals and surgeons were mainly driven by differences in patient populations undergoing lumbar fusion, suggesting that PROs may not be useful indicators of hospital or surgeon quality. Careful patient selection using validated prediction tools may decrease differences in outcomes across hospitals and providers and improve overall quality, but would significantly reduce surgical volumes. Level of Evidence: 3

Different Approaches for Case-Mix Adjustment of Patient-Reported Outcomes to Compare Healthcare Providers—Methodological Results of a Systematic Review

“…Five inpatient settings [20][21][22][23][24], five outpatient settings [25][26][27][28][29], one mental health services setting [26], and three rehabilitation settings [20,28,29] were identified. Ten studies included patients with orthopedic conditions [20][21][22][23][24][25][27][28][29][30]. Three of the studies included were set in National Health Service-funded hospitals in the United Kingdom [21,23,30].…”

“…All of the studies included explored PROs for an adult population. Ten studies were conducted in orthopedic settings [20][21][22][23][24][25][27][28][29][30], and one investigated patients with psychiatric conditions [26]. None of the studies that were identified investigated PROs in populations of cancer patients.…”

“…Two studies stated that they chose the adjustors that were used on the basis of statistical parameters: Resnik and Hart used bivariate analysis to identify suitable adjustors [28], and Deutscher et al employed a back-step regression model [25]. Farin et al and Khor et al based their choice of adjustors on earlier findings by their research groups [20,22]. Table 2 provides further information.…”

“…One study investigated the proportion of patients who experienced an improvement of at least one minimally important difference (MID) as the outcome of interest-i.e., they dichotomized the original PRO score [22]. They then calculated the expected number of events per provider on the basis of a previously published risk calculator, calculated the observed/expected ratio, and finally calculated the case-mix-adjusted event rate by multiplying the O/E ratio by the overall state-wide average.…”

The effects of preoperative imaging stability studies on intraoperative correction, postoperative observation, and clinical efficacy of adult lumbar spondylolisthesis treatment

“…Khor S et al Reported that surgical fusion of an unstable lumbar spine can successfully correct lumbar spine stability [4] . Traditionally, conservative treatment for lumbar spondylolisthesis is considered for patients with mild symptoms, and surgical treatment recommended for patients with severe symptoms that affect their daily life, and those that failed conservative treatment [5] .…”