Is there bias in the treatment of degenerative spine disease? Analysis of anonymous voting via a multidisciplinary conference.

Many institutions have developed shared decision-making conferences as a mechanism for reducing treatment costs and improving patient outcomes. Little is known about the process of shared decision-making that takes place in these conferences, and there is the possibility of bias among surgeons and nonsurgeons for treatment within their respective specialties. This study was conducted to determine who is contributing to the decision-making process in a multidisciplinary spine conference and to what extent treatment biases exist among the surgical and nonsurgical members of this conference. Voting data were collected during weekly multidisciplinary spine conferences. Descriptive statistics were calculated on the cases presented and the number and type of physicians voting for each case. The likelihood of a particular vote in the surgeon and nonsurgeon cohorts was evaluated using relative risk calculation and multinomial logistic regression. A total of 262 consecutive cases were analyzed. No significant differences in treatment recommendation were observed between surgery and nonsurgical management (relative risk, 1.1; 95% CI, 0.97-1.25) when comparing votes from the surgeon and nonsurgeon cohorts. Multinomial logistic regression showed the odds of nonsurgeons recommending nonsurgical management over surgery was 20% greater than receiving that recommendation from their surgeon colleagues. Individual surgeon and nonsurgeon voters were evenly distributed above and below the mean for treatment recommendation. Individual and group biases exist among surgeons and nonsurgeons treating degenerative spine diseases. Multidisciplinary conferences may or may not level these biases, depending on how they are conducted.

A systematic multidisciplinary initiative for reducing the risk of complications in adult scoliosis surgery.

OBJECTIVE Systematic multidisciplinary approaches to improving quality and safety in complex surgical care have shown promise. Complication rates from complex spine surgery range from 10% to 90% for all surgeries, and the overall mortality rate is 1%-4%. These rates suggest the need for improved perioperative complex spine surgery processes designed to minimize risk and improve quality. METHODS The Group Health Research Institute and Virginia Mason Medical Center implemented a systematic multidisciplinary protocol, the Seattle Spine Team Protocol, in 2010. This protocol involves the following elements: 1) a comprehensive multidisciplinary conference including clinicians from neurosurgery, anesthesia, orthopedics, internal medicine, behavioral health, and nursing, collaboratively deciding on each patient's suitability for surgery; 2) a mandatory patient education course that reviews the risks of surgery, preparation for the surgery, and postoperative care; 3) a dual-attending-surgeon approach involving 1 neurosurgeon and 1 orthopedic spine surgeon; 4) a dedicated specialist complex spine anesthesia team; and 5) rigorous intraoperative monitoring of a patient's blood loss and coagulopathy. The authors identified 71 patients who underwent complex spine surgery involving fusion of 6 or more levels before implementation of the protocol (surgery between 2008 and 2010) and 69 patients who underwent complex spine surgery after the implementation of the protocol (2010 and 2012). All patient demographic variables, including age, sex, body mass index, smoking status, diagnosis of diabetes and/or osteoporosis, previous surgery, and the nature of the spinal deformity, were comprehensively assessed. Also comprehensively assessed were surgical variables, including operative time, number of levels fused, and length of stay. The authors assessed overall complication rates at 30 days and 1 year and detailed deaths, cardiovascular events, infections, instrumentation failures, and CSF leaks. Chi-square and Wilcoxon rank-sum tests were used to assess differences in patient characteristics for patients with a procedure in the preimplementation period from those in the postimplementation period under a Poisson distribution model. RESULTS Patients who underwent surgery after implementation of the Seattle Spine Team Protocol had a statistically significant reduction (relative risk 0.49 [95% CI 0.30-0.78]) in all measured complications, including cardiovascular events, wound infections, other perioperative infections, and implant failures within 30 days after surgery; the analysis was adjusted for age and Charlson comorbidity score. A trend toward fewer deaths in this group was also found. CONCLUSIONS This type of systematic quality improvement strategy can improve quality and patient safety and might be applicable to other complex surgical disciplines. Implementation of these strategies in the treatment of adult spinal deformity will likely lead to better patient outcomes.

Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study.

STUDY DESIGN: Observational cohort pilot study. OBJECTIVE: To determine the impact of a multidisciplinary conference on treatment decisions for lumbar degenerative spine disease. SUMMARY OF BACKGROUND DATA: Multidisciplinary decision making improves outcomes in many disciplines. The lack of integrated systems for comprehensive care for spinal disorders has contributed to the inappropriate overutilization of spine surgery in the United States. METHODS: We implemented a multidisciplinary conference involving physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff. Over 10 months, we presented patients being considered for spinal fusion or who had a complex history of prior spinal surgery. We compared the decision to proceed with surgery and the proposed surgical approach proposed by outside surgeons with the consensus of our multidisciplinary conference. We also assessed comprehensive demographics and comorbidities for the patients and examined outcomes for surgical patients. RESULTS: A total of 137 consecutive patients were reviewed at our multidisciplinary conference during the 10-month period. Of these, 100 patients had been recommended for lumbar spine fusion by an outside surgeon. Consensus opinion of the multidisciplinary conference advocated for nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution (χ  = 26.6; P < 0.01). Furthermore, the surgical treatment plan was revised as a product of the conference in 28% (16 patients) of the patients who ultimately underwent surgery (χ  = 43.6; P < 0.01). We had zero 30-day complications in surgical patients. CONCLUSION: Isolated surgical decision making may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse nonoperative treatment options. Although long-term patient outcomes remain to be determined, such multidisciplinary care will likely be essential to improving the quality and value of spine care. LEVEL OF EVIDENCE: 3.

The Employer-Led Health Care Revolution.

To tame its soaring health care costs, intel tried many popular approaches: "consumer-driven health care" offerings such as high-deductible/low-premium plans, on-site clinics and employee wellness programs. But by 2009 intel realized that those programs alone would not enable the company to solve the problem, because they didn't affect its root cause: the steadily rising cost of the care employees and their families were receiving. Intel projected that its health care expenditures would hit a whopping $1 billion by 2012. So the company decided to try a novel approach. As a large purchaser of health services and with expertise in quality improvement and supplier management, intel was uniquely positioned to drive transformation in its local health care market. The company decided that it would manage the quality and cost of its health care suppliers with the same rigor it applied to its equipment suppliers by monitoring quality and cost. It spearheaded a collaborative effort in Portland, Oregon, that included two health systems, a plan administrator, and a major government employer. So far the Portland collaborative has reduced treatment costs for certain medical conditions by 24% to 49%, improved patient satisfaction, and eliminated over 10,000 hours worth of waste in the two health systems' business processes.

Improving acute respiratory infection care through nurse phone care and academic detailing of physicians.

INTRODUCTION: To address unnecessary use of antibiotics for uncomplicated acute respiratory infection, we implemented a standardized care pathway composed of: (1) academic detailing of primary care providers, and (2) telephonic care from nurses. METHODS: To evaluate the intervention, we performed a retrospective time series study and cost analysis at a primary care provider network in the Pacific Northwest with 118 providers at seven sites. The main outcomes were: (1) antibiotic rate, (2) provider visits avoided, and (3) cost savings from the payer and health care system perspectives. Data were collected for January 2, 2010 to November 30, 2013, with the interventions occurring on March 1, 2012. RESULTS: There were 54,283 acute upper respiratory infection visits (34,678 [64%] female; average age, 52.1 years). After the intervention, nurse phone consultation involved 13.8% (3,289 of 23,769) of care episodes. The intervention was associated with a 16.5% absolute decrease in antibiotic rate (95% CI, -0.205 to -0.125; P < .001), after adjustment. Post intervention, 1983 of 23,769 (8.3%) episodes did not require any provider visit (1133 per year). Single institution cost savings to payers exceeded $175,000. CONCLUSIONS: Implementation of nurse phone care and provider academic detailing was associated with lower inappropriate antibiotic usage and fewer unnecessary provider visits.

At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality.

Virginia Mason Medical Center in Seattle has worked in collaboration with health plans and employers to facilitate development of standardized approaches to care of patients with common conditions. These efforts have eliminated unnecessary treatment and decreased costs to employers, health plans, patients, and providers. We describe our collaborative approach and illustrate it with the example of improved treatment for patients with uncomplicated headache, for which we have achieved 91 percent patient satisfaction, decreased use of advanced imaging by 23 percent, and provided same-day appointments in 95 percent of cases. As a model for improving quality while reducing cost, the Virginia Mason experience demonstrates that a multispecialty group practice, hospital, employers, and health plans can define quality and align performance and payment along common goals.

Effectiveness of clinical decision support in controlling inappropriate imaging.

BACKGROUND: Decision support systems for advanced imaging are being implemented with increased frequency and are mandated under some new governmental health care initiatives. However, evidence of effectiveness in reducing inappropriate imaging utilization is limited. METHODS: A retrospective cohort study was performed of the staged implementation of evidence-based clinical decision support built into ordering systems for selected high-volume imaging procedures: lumbar MRI, brain MRI, and sinus CT. Brain CT was included as a control. Imaging utilization rates (number of patients imaged as a proportion of patients with selected clinical conditions) and overall imaging utilization before and after the interventions were determined from billing data from a regional health plan and from the institutional radiology information system. RESULTS: The use of imaging clinical decision support was associated with substantial decreases in the utilization rate of lumbar MRI for low back pain (risk ratio, 0.77; 95% confidence interval, 0.87-0.67; P = .0001), head MRI for headache (risk ratio, 0.76; 95% confidence interval, 0.91-0.64; P = .001), and sinus CT for sinusitis (risk ratio, 0.73; 95% confidence interval, 0.82-0.65; P < .0001). Utilization rates for the head CT control group were not significantly changed. There was a corresponding significant decrease in overall imaging volumes (all diagnoses) for lumbar MRI, head MRI, and sinus CT, with no observed effect for the head CT control group. CONCLUSION: Targeted use of imaging clinical decision support is associated with large decreases in the inappropriate utilization of advanced imaging tests.