The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry. CONCLUSIONS In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVEThe Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.METHODSA total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.RESULTSNinety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.CONCLUSIONSA multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery.

OBJECTIVE: As compensation transitions from a fee-for-service to pay-for-performance healthcare model, providers must prioritize patient-centered experiences. Here, the authors' primary aim was to identify predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) was queried for all lumbar operations at the 1- and 2-year follow-ups. Predictors of patients' postoperative contentment were identified per the North American Spine Surgery (NASS) Patient Satisfaction Index, wherein satisfied patients were assigned a score of 1 ("the treatment met my expectations") or 2 ("I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome") and unsatisfied patients were assigned a score of 3 ("I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome") or 4 ("I am the same or worse than before treatment"). Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios (RRadj). RESULTS: Among 5390 patients with a 1-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by higher body mass index (RRadj =1.07, p < 0.001), African American race compared to white (RRadj = 1.51, p < 0.001), education level less than high school graduation compared to a high school diploma or equivalent (RRadj = 1.25, p = 0.008), smoking (RRadj = 1.34, p < 0.001), daily preoperative opioid use > 6 months (RRadj = 1.22, p < 0.001), depression (RRadj = 1.31, p < 0.001), symptom duration > 1 year (RRadj = 1.32, p < 0.001), previous spine surgery (RRadj = 1.32, p < 0.001), and higher baseline numeric rating scale (NRS)-back pain score (RRadj = 1.04, p = 0.002). Conversely, an education level higher than high school graduation, independent ambulation (RRadj = 0.90, p = 0.039), higher baseline NRS-leg pain score (RRadj = 0.97, p = 0.013), and fusion surgery (RRadj = 0.88, p = 0.014) decreased dissatisfaction.Among 2776 patients with a 2-year follow-up, 22% reported dissatisfaction postoperatively. Dissatisfaction was predicted by a non-white race, current smoking (RRadj = 1.26, p = 0.004), depression (RRadj = 1.34, p < 0.001), symptom duration > 1 year (RRadj = 1.47, p < 0.001), previous spine surgery (RRadj = 1.28, p < 0.001), and higher baseline NRS-back pain score (RRadj = 1.06, p = 0.003). Conversely, at least some college education (RRadj = 0.87, p = 0.035) decreased the risk of dissatisfaction. CONCLUSIONS: Both comorbid conditions and socioeconomic circumstances must be considered in counseling patients on postoperative expectations. After race, symptom duration was the strongest predictor of dissatisfaction; thus, patient-centered measures must be prioritized. These findings should serve as a tool for surgeons to identify at-risk populations that may need more attention regarding effective communication and additional preoperative counseling to address potential barriers unique to their situation.