Effective Value-Based Initiatives for Complex Spine Surgery

Peer Reviewed

Effective methods to increase the value equation in complex spine surgery include standardization, team-based and collaborative approaches, outcomes tracking, and continuous process improvement. These methods have been found to both improve outcomes and reduce costs in pediatric and adult complex spine surgeries, according to a review of the expert opinion of leading spine specialists published in the March issue of Spine Deformity.
Team of surgeons at work in the operating room."A combined focus on safety and value has become necessary for centers that perform complex spinal procedures for spinal deformity". Photo Source: 123RF.com.“A combined focus on safety and value has become necessary for centers that perform complex spinal procedures for spinal deformity,” explained lead author Rajiv K. Sethi, MD, who is Director of the Neuroscience Institute and Director of the Complex Spine Surgery and Spine Center of Excellence Programs at Virginia Mason Medical Center and Clinical Professor of Health Services Research at the University of Washington in Seattle, WA.

“Surgeons should lead many of these efforts and they are the best to do so while keeping the patient at the top of the pyramid,” Dr. Sethi told SpineUniverse. “Leading centers around of the world have used standardized protocols, registries and LEAN methodology to enhance safety and value in the care of complex spine patients.”

Top Methods to Increase Value in Complex Spine Surgery

Dr. Sethi said that use of lean principles and monitoring outcomes through registries are among the top methods that increase value in complex spine surgery.

“The use of LEAN methodology to create standard work protocols allows centers to root out variability, variability being the major source for value degradation in the care of spine patients,” Dr. Sethi explained. “Creating institutional and national registries is also a very important method to standardize outcomes.”

Outcomes registries can be used in different ways including for “individual patient care evaluation, continuous evaluation of quality of care delivered in a defined subgroup of patients, case-mix, and risk-corrected benchmark between professionals and institutions, value-based health care, research (eg comparative effectiveness), and more specifically decision support,” Dr. Sethi and colleagues noted. For example, an international consensus on a standard set of core outcomes for adolescents and young adults with a spine deformity undergoing reconstructive surgery was recently published.1

Other methods outlined in the paper include:

  • Standardized post-operative care pathways following posterior spinal fusion for adolescent idiopathic scoliosis
  • Co-management pathways coordinating care between surgical and medical teams for adult spine surgery
  • LEAN operating room teams
  • Use of Comprehensive Unit Based Safety Programs (CUSP) to improve surgical team cohesion
  • Continuous mentorship and dual attending surgeon approaches

Dr. Sethi’s research in this field lead to development of a recently published a spine safety improvement model that includes key factors needed at the individual, team, and organizational level to guide quality and safety improvement initiatives (Figure).2 Dashboards and registries can be used to determine whether the items in this algorithm are leading to less variability and greater predictability in terms of outcomes, the authors noted.
Figure. The Spine Safety Improvement Model - Conceptual (SpineSIM-C). Reprinted with permission from Sethi et al.2Figure. The Spine Safety Improvement Model - Conceptual (SpineSIM-C). Reprinted with permission from Sethi et al.2Figure. The Spine Safety Improvement Model - Conceptual (SpineSIM-C). Reprinted with permission from Sethi et al.2

Which Methods Are Underused?

“Multidisciplinary clearance conferences remain a very effective way to bring many of the care providers to the table and make informed decisions on patients with complex medical and surgical pathology,” Dr. Sethi told SpineUniverse. “While this is being done in many centers with high volumes of complex spine patients, it is still underutilized in many settings where there is a lack of standardized management in the care of this difficult patient population.”

Dr. Sethi and colleagues concluded that surgeon leadership is needed to develop standardized, team-based approaches in complex spine surgery that will deliver high value care patients.

Findings Are “Compelling”, Expert Says

“With this impressive work, Dr. Sethi and his colleagues have presented a compelling and critical contribution to the spine surgery literature,” commented SpineUniverse editorial board member Ali A. Baaj, MD. “Planning and executing effective standardization pathways in complex spine surgery undoubtedly improves outcomes and lowers cost, and thus magnifies the value of what we do.”

“The authors provide proven strategies and mechanisms to lower costs but not compromise safety,” said Dr. Baaj, who is Associate Professor of Neurological Surgery and Co-Director of the Spinal Deformity and Scoliosis Program Weill Cornell Medical College, Cornell University, New York, NY. “All spinal deformity surgeons and their respective teams, especially at high volume centers, should consider implementing such strategies.”

“I completely concur that, unless we as spine surgeons take the initiative to demonstrating and improving the value of our work, regulatory bodies and payer groups may one day deprive our patients from the excellent care we know we can provide to them.”

Disclosures
Dr. Sethi has no relevant disclosures.

Updated on: 03/11/19
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Pre-Operative Planning Reduces Complication Risk in Adult Spinal Deformity Surgery
Rajiv K. Sethi, MD
Clinical Associate Professor
Department of Health Services
University of Washington
Ali A. Baaj, MD
Associate Professor, Neurological Surgery
Weill Cornell Medical College
Cornell University
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