The interrater reliability of Modic changes among a potential basivertebral nerve ablation population: Why AC1 may be preferred to kappa.

Interrater reliability of Modic changes is subject to variables which affect consistency in reporting. Given the importance of Modic change identification for basivertebral nerve ablation (BVNA) candidacy, interrater reliability for this specific cohort has not yet been reported. Twenty lumbar magnetic resonance images of potential basivertebral nerve candidates were independently reviewed by two neuroradiologists and two interventional spine physiatrists for the presence and characterization of Modic changes. The kappa value of their agreement on the presence of Modic changes was 0.52 (95% confidence interval [CI] 0.37-0.67), whereas agreement on the type of Modic change was 0.51 (95% CI 0.37-0.65). Using an alternative methodology for measuring interrater reliability (Gwet's AC1) yielded the identification of the presence of Modic changes at AC1 0.51 (95% CI 0.36-0.66), whereas agreement on the type of Modic change was AC1 0.75 (95% CI 0.66-0.83). While less common, AC1 may be preferred in the appropriate cohort to kappa as it mitigates some of the pitfalls to which kappa values may be victim. Ultimately, our results are in-line with previous reports of interrater reliability results for Modic changes in other cohorts and should serve to caution those who perform BVNA regarding interrater agreement of the imaging crux of the procedure.

The Clinical Significance of the Modic Changes Grading Score.

STUDY DESIGN: Cross-sectional retrospective observational study. OBJECTIVE: To evaluate the reliability and clinical utility of the Modic changes (MC) grading score. METHOD: Patients from the Danish national spine registry, DaneSpine, scheduled for lumbar discectomy were identified. MRI of patients with MC were graded based on vertical height involvement: Grade A (<25%), Grade B (25%-50%), and Grade C (>50%). All MRIs were reviewed by 2 physicians to evaluate the reliability of the MC grade. RESULTS: Of 213 patients included, 142 patients had MC, 71 with MC-1 and 71 with MC-2; 34% were Grade A, 45% were Grade B, and 21% were Grade C. MC grade demonstrated substantial intra-rater (κ = .68) and inter-rater (κ = .61) reliability. A significantly higher proportion (n = 40, 57%) of patients with MC-1 had a severe MC grade compared to patients with MC-2 (n = 30, 43%, P < .001). Severe MC grade was associated with the presence of severe lumbar disc degeneration (DD) (Pfirrmann grade = V, P = .024), worse preoperative ODI (52.49 vs 44.17, P = .021) and EQ-5D scores (.26 vs .46, P = .053). MC alone including type was not associated with a significant difference in patient-reported outcomes (P > .05). CONCLUSION: The MC grade score was demonstrated to have substantial intra- and inter-observer reliability. Severe MC grade was associated with both severe DD and MC type, being more prevalent in patients with MC-1. The MC grade was also significantly associated with worse disability and reduced health-related quality of life. Results from the study suggest that MC grade is more clinically important than MC type.

A First Estimate of the Annual Prevalence of Basivertebral Nerve Ablation Candidates in a Spine Clinic.

BACKGROUND: Emerging literature supports the use of basivertebral nerve ablation (BVNA) for a specific cohort of patients with chronic low back pain and Type 1 or Type 2 Modic changes from vertebral levels L3-S1. The early literature warrants further evaluation. Studies establishing the efficacy of BVNA use highly selective patient criteria. OBJECTIVE: Provide a first estimate of the prevalence of BVNA candidates in a spine clinic over a year using the foundational studies patient selection criteria? METHODS: A retrospective review of four fellowhsip trained spine physiatrists patient encounters at a large academic medical center using relevant ICD-10 codes to isolate chronic low back pain without radiating symptoms from January 1, 2019 to January 1, 2020. Charts were then reviewed by a team of physicians for exclusionary criteria from the foundational studies which have demonstrated benefit from BVNA. MRI's from qualifying charts which did not meet exclusionary criteria were then independently reviewed by four physician for localization and characterization of Modic changes. RESULTS: The relevant diagnostic codes query yielded 338 unique patient records. Based on exclusionary criteria or lack of imaging availability, 318 charts were eliminated. The remaining 20 charts qualified for imaging review. There were 11 charts in which there was 100% agreement between all reviewers regarding the presence and either Type 1 or Type 2 Modic changes between vertebral levels L3 to S1. Accordingly, the prevalence of eligibility for BVNA was 3% (11/338, 95% CI 1-5%). CONCLUSION: The population which may benefit from BVNA is small. Our study demonstrated that over a year, the prevalence for BVNA candidacy using the foundational studies criteria was 3% (95% CI 1% - 5%). While physicians may be tempted to use less stringent selection criteria in practice, upon doing so they cannot cite the foundational studies as evidence for the outcomes they expect to achieve. Those outcomes will require more studies which formally assess the benefits of BVNA when selection criteria are relaxed.

A definition and clinical grading of Modic changes.

To provide an up-to-date description of knowledge and pitfalls related to the classification, definition and grading of Modic changes (MC) visualized on magnetic resonance imaging (MRI). State-of-the-art review of current knowledge regarding the definition and grading of MC on MRI. MC on MRI have been reported to be associated with low back pain and disability. However, previous studies have shown heterogeneous results in regards to the impact of MC and its clinical relevance in patients with back pain. MC is a term used with considerable variation in the literature. No strict definition has been provided previously, this has contributed to varying diagnostic inclusion criteria, heterogeneous study populations, and discrepancy in results. A definition of MC and a proposal for grading is provided in this state-of-the-art review. MC are important, clinically relevant findings. However, issues with the nomenclature, definition and grading of these changes need to be addressed. Our current review highlights relevant issues related to MC, and provides a definition and grading score for the term MC that includes the Modic type and the extent of vertebral body involvement. Future studies should seek to validate the MC grading score in clinically relevant populations.

A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care.

BACKGROUND: The standardization of care along disease lines is recommended to improve outcomes and reduce health care costs. The multiple disciplines involved in concussion management often result in fragmented and disparate care. A fundamental gap exists in the effective utilization of rehabilitation services for individuals with concussion. PURPOSE: The purpose of this project was to (1) characterize changes in health care utilization following implementation of a concussion carepath, and (2) present an economic evaluation of patient charges following carepath implementation. DESIGN: This was a retrospective cohort study. METHODS: A review of electronic medical and financial records was conducted of individuals (N = 3937), ages 18 to 45 years, with primary diagnosis of concussion who sought care in the outpatient or emergency department settings over a 7-year period (2010-2016). Outcomes including encounter length, resource utilization, and charges were compared for each year to determine changes from pre- to post-carepath implementation. RESULTS: Concussion volumes increased by 385% from 2010 to 2015. Utilization of physical therapy increased from 9% to 20% while time to referral decreased from 72 to 23 days post-injury. Utilization of emergency medicine and imaging were significantly reduced. Efficient resource utilization led to a 20.7% decrease in median charges (estimated ratio of means [CI] 7.72 [0.53, 0.96]) associated with concussion care. LIMITATIONS: Encounter lengths served as a proxy for recovery time. CONCLUSIONS: The implementation of the concussion carepath was successful in optimizing clinical practice with respect to facilitating continuity of care, appropriate resource utilization, and effective handoffs to physical therapy. The utilization of enabling technology to facilitate the collection of common outcomes across providers was vital to the success of standardizing clinical care without compromising patient outcomes.

Association of Cavum Septum Pellucidum and Cavum Vergae With Cognition, Mood, and Brain Volumes in Professional Fighters.

Importance: Many studies have investigated the imaging findings showing sequelae of repetitive head trauma, with mixed results. Objective: To determine whether fighters (boxers and mixed martial arts fighters) with cavum septum pellucidum (CSP) and cavum vergae (CV) have reduced volumes in various brain structures or worse clinical outcomes on cognitive and mood testing. Design, Setting, and Participants: This cohort study assessed participants from the Professional Fighters Brain Health Study. Data were collected from April 14, 2011, to January 17, 2018, and were analyzed from September 1, 2018, to May 23, 2019. This study involved a referred sample of 476 active and retired professional fighters. Eligible participants were at least 18 years of age and had at least a fourth-grade reading level. Healthy age-matched controls with no history of trauma were also enrolled. Exposures: Presence of CSP, CV, and their total (additive) length (CSPV length). Main Outcomes and Measures: Information regarding depression, impulsivity, and sleepiness among study participants was obtained using the Patient Health Questionnaire depression scale, Barrett Impulsiveness Scale, and the Epworth Sleepiness Scale. Cognition was assessed using raw scores from CNS Vital Signs. Volumes of various brain structures were measured via magnetic resonance imaging. Results: A total of 476 fighters (440 men, 36 women; mean [SD] age, 30.0 [8.2] years [range, 18-72 years]) and 63 control participants (57 men, 6 women; mean [SD] age, 30.8 [9.6] years [range, 18-58 years]) were enrolled in the study. Compared with fighters without CV, fighters with CV had significantly lower mean psychomotor speed (estimated difference, -11.3; 95% CI, -17.4 to -5.2; P = .004) and lower mean volumes in the supratentorium (estimated difference, -31 191 mm3; 95% CI, -61 903 to -479 mm3; P = .05) and other structures. Longer CSPV length was associated with lower processing speed (slope, -0.39; 95% CI, -0.49 to -0.28; P < .001), psychomotor speed (slope, -0.43; 95% CI, -0.53 to -0.32; P < .001), and lower brain volumes in the supratentorium (slope, -1072 mm3 for every 1-mm increase in CSPV length; 95% CI, -1655 to -489 mm3; P < .001) and other structures. Conclusions and Relevance: This study suggests that the presence of CSP and CV is associated with lower regional brain volumes and cognitive performance in a cohort exposed to repetitive head trauma.

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion.

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery - acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

Spine Surgeon Treatment Variability: The Impact on Costs.

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.

The Global Spine Care Initiative: model of care and implementation.

PURPOSE: Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions. METHODS: The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps. RESULTS: Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up. CONCLUSION: The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: classification system for spine-related concerns.

PURPOSE: The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway. METHODS: Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. RESULTS: Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended. CONCLUSIONS: An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures.

PURPOSE: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. METHODS: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. RESULTS: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. CONCLUSION: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities.

PURPOSE: Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources. METHODS: Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders. RESULTS: Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care. CONCLUSION: The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: care pathway for people with spine-related concerns.

PURPOSE: The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally. METHODS: The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used. RESULTS: After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records. CONCLUSION: A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities.

PURPOSE: The purpose of this systematic literature review was to develop recommendations for the assessment of spine-related complaints in medically underserved areas with limited resources. METHODS: We conducted a systematic review and best evidence synthesis of guidelines on the assessment of spine-related complaints. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation-II criteria. Low risk of bias clinical practice guidelines was used to develop recommendations. In accordance with the mandate of the Global Spinal Care Initiative (GSCI), recommendations were selected that could be applied to medically underserved areas and low- and middle-income countries by considering the limited access and costs of diagnostic technologies. RESULTS: We screened 3069 citations; 20 guidelines were eligible for critical appraisal. We used 13 that had a low risk of bias that targeted neck and back pain. CONCLUSIONS: When assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care. These slides can be retrieved under Electronic Supplementary Material.

Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons.

BACKGROUND: There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. OBJECTIVE: To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. METHODS: 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S-BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. RESULTS: There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S-BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. CONCLUSIONS: Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.

Cost Analysis of the Addition of Hyperacute Magnetic Resonance Imaging for Selection of Patients for Endovascular Stroke Therapy.

BACKGROUND AND PURPOSE: Patient selection is important to determine the best candidates for endovascular stroke therapy. In application of a hyperacute magnetic resonance imaging (MRI) protocol for patient selection, we have shown decreased utilization with improved outcomes. A cost analysis comparing the pre- and post-MRI protocol time periods was performed to determine if the previous findings translated into cost opportunities. MATERIALS AND METHODS: We retrospectively identified individuals considered for endovascular stroke therapy from January 2008 to August 2012 who were ≤8 h from stroke symptoms onset. Patients prior to April 30, 2010 were selected based on results of the computed tomography/computed tomography angiography alone (pre-hyperacute), whereas patients after April 30, 2010 were selected based on results of MRI (post-hyperacute MRI). Demographic, outcome, and financial information was collected. Log-transformed average daily direct costs were regressed on time period. The regression model included demographic and clinical covariates as potential confounders. Multiple imputation was used to account for missing data. RESULTS: We identified 267 patients in our database (88 patients in pre-hyperacute MRI period, 179 in hyperacute MRI protocol period). Patient length of stay was not significantly different in the hyperacute MRI protocol period as compared to the pre-hyperacute MRI period (10.6 vs. 9.9 days, p < 0.42). The median of average daily direct costs was reduced by 24.5% (95% confidence interval 14.1-33.7%, p < 0.001). CONCLUSIONS: Use of the hyperacute MRI protocol translated into reduced costs, in addition to reduced utilization and better outcomes. MRI selection of patients is an effective strategy, both for patients and hospital systems.

Value in Single-level Lumbar Discectomy: Surgical Disposable Item Cost and Relationship to Patient-reported Outcomes.

STUDY DESIGN: This is a retrospective study. OBJECTIVE: Compare improvements in health status measures (HSMs) and surgical costs to determine whether use of more costly items has any relationship to clinical outcome and value in lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Association between cost, outcomes, and value in spine surgery, including lumbar discectomy is poorly understood. Outcomes were calculated as difference in mean HSM scores between preoperative and postoperative timeframes. Prospective validated patient-reported HSMs studied were EuroQol quality of life index score (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire (PHQ-9). Surgical costs consisted of disposable items and implants used in operating room. METHODS: We retrospectively identified all adult patients at Cleveland Clinic main campus between October 2009 and August 2013 who underwent lumbar discectomy (652) using administrative billing data, Current Procedural Terminology (CPT) code 63030. HSMs were obtained from Cleveland Clinic Knowledge Program Data Registry. RESULTS: In total, 67% of operations performed in the outpatient or ambulatory setting, 33% in the inpatient setting. Among 9 surgeons who performed >10 lumbar discectomies, there were 72.4 operations per surgeon, on average. Mean surgical costs of each surgeon differed (P<0.0001). In a multivariable regression, only the surgeon and surgery type (outpatient or inpatient) were statistically correlated with surgical costs (P<0.0001 and 0.046, respectively). Changes in EQ-5D, PDQ, and PHQ-9 were not correlated with surgical costs (P=0.76, 0.07, 0.76, respectively). In multivariable regression, only surgical cost was significantly correlated to mean difference in PDQ (P=0.030). More costly surgeries resulted in worse PDQ outcomes. CONCLUSIONS: Mean surgical costs varied statistically among 9 surgeons; costs were not shown to be positively correlated with patient outcomes. Performing an operation using more costly disposable supplies/implants does not seem to improve patient outcomes and should be considered when constructing preference cards and during an operation.

The Association Between Operating Room Personnel and Turnover With Surgical Site Infection in More Than 12 000 Neurosurgical Cases.

BACKGROUND: Surgical site infection (SSI) contributes significantly to postoperative morbidity and mortality and greatly increases the cost of care. OBJECTIVE: To identify the impact of workflow and personnel-related risk factors contributing to the incidence of SSIs in a large sample of neurological surgeries. METHODS: Data were obtained using an enterprisewide electronic health record system, operating room, and anesthesia records for neurological procedures conducted between January 1, 2009, and November 30, 2012. SSI data were obtained from prospective surveillance by infection preventionists using Centers for Disease Control and Prevention definitions. A multivariate model was constructed and refined using backward elimination logistic regression methods. RESULTS: The analysis included 12 528 procedures. Most cases were elective (94.5%), and the average procedure length was 4.8 hours. The average number of people present in the operating room at any time during the procedure was 10.0. The overall infection rate was 2.3%. Patient body mass index (odds ratio, 1.03; 95% confidence interval [CI], 1.01-1.04) and sex (odds ratio, 1.36; 95% CI, 1.07-1.72) as well as procedure length (odds ratio, 1.19 per additional hour; 95% CI, 1.15-1.23) and nursing staff turnovers (odds ratio, 1.095 per additional turnover; 95% CI, 1.02-1.21) were significantly correlated with the risk of SSI. CONCLUSION: This study found that patient body mass index and male sex were associated with an increased risk of SSI. Operating room personnel turnover, a modifiable, work flow-related factor, was an independent variable positively correlated with SSI. This study suggests that efforts to reduce operating room turnover may be effective in preventing SSI. ABBREVIATIONS: OR, operating roomSSI, surgical site infection.

Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States.

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.

Electronic Stroke CarePath: Integrated Approach to Stroke Care.

We describe the development, implementation, and outcomes of the first 2 years of the Electronic Stroke CarePath, an initiative developed for management of ischemic stroke patients in an effort to improve efficiency and quality of care for patients. The CarePath consists of care pathways for ischemic stroke that are integrated within the electronic health record. Patient-reported outcomes are collected using an external software platform. Documentation tools, order sets, and clinical decision support were designed to improve efficiency, optimize process measure adherence, and produce clinical data as a byproduct of care that are available for future analyses. Inpatient mortality and length of stay were compared before and after CarePath implementation in ischemic stroke patients after adjustment for case-mix. Postdischarge functional outcomes of patients with ischemic stroke were compared between the first 3 months of rollout and remainder of the study period. From January 2011 to December 2012, there were 1106 patients with ischemic stroke on the CarePath. There was a decline in inpatient mortality in patients with ischemic stroke, but not in control patients with intracerebral or subarachnoid hemorrhage. Completion rate of patient-reported questionnaires at postdischarge stroke follow-up was 72.9%. There was a trend toward improved functional outcomes at follow-up with CarePath implementation. Implementation of the Electronic Stroke CarePath is feasible and may be associated with a benefit in multiple different outcomes after ischemic stroke. This approach may be an important strategy for optimizing stroke care in the future.