Neurosurgery
The John Ratliff Lab

The John Ratliff Lab Research

Outcomes assessment:  Database modelling

Understanding and interpreting databases are vital to neurosurgery training and to development of new surgical and conservative treatments for patients.  In February 2009, the Federal Coordinating Council of Comparativeness Effectiveness Research (CER) was established with the purpose to “foster optimum coordination of comparative effectiveness and related health services research conducted or supported by relevant federal departments and agencies, with the goal of reducing duplicative efforts and encouraging coordinated and complementary use of resources”(www.ahrq.gov/fund/cefarraexc.htm). Outcomes research and comparative effectiveness research will be foundations for health care reform, delivery, and reimbursement policies. CER efforts are a prime focus of the Affordable Care Act (ACA) and are a central tenant of the Patient Centered Outcomes Research Initiative (PCORI). 

Because there exists significant costs, complication rates and variations in neurosurgical procedures, neurosurgical outcomes research will play a fundamental role the future of healthcare. The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) have intensified their outcomes research efforts.   Neurosurgery’s national organizations are developing an outcomes database that patients may be enrolled in. However, at present this effort is in its infancy.  This research effort will focus only upon operative patient, and may not fully capture the complexity of neurosurgical treatments.

The environment at Stanford makes it ideal for the development of a world class neurosurgical outcomes program. We propose to develop a neurosurgical database and outcomes research center with two goals:

1. To establish a center of excellence in outcomes research with the following objectives:

    • To become an international leader in evidence based neurosurgery and outcomes research.
    • Identify processes of care that lead to superior outcomes in neurosurgery
    • Develop predictive models of outcomes identifying preoperative risk factors for adverse events in neurosurgery procedures
    • Perform cost effectiveness and comparative effectiveness studies of neurosurgical disorders.
    • Foster resident research and development of young resident neurosurgeons as scholars in outcomes research
    • Successfully compete for NIH extramural and other federal and private foundation grants.

2. To develop descriptive and predictive models of health systems disparity in neuroscience and neurosurgical patient care, concentrating upon economic, social, ethnic, and geographic barriers to care faced by patients.

While much research has been devoted to individual procedures and to patients that have undergone surgical care in the neurosciences, limited work has been directed at disparities in neuroscience and neurosurgical care.  Exploring these issues will provide great insight into the challenges faced by many of our patient and may direct the efforts of social programs in neuroscience care.

These goals may be accomplished at present by assessment of extant databases, including commercial databases such as Marketscan, maintained by a division of Thomson Reuters, the Medicare and Medicaid databases, maintained by the Centers for Medicare and Medicaid services, the California Inpatient Database, and a variety of cancer registries.  Each of these databases provides a piece of the clinical puzzle, by incorporating multiple databases into our inquiry we believe we have the greatest opportunity to succeed. 

Outcomes assessment:  the Stanford Spine Registry

The Stanford Spine Database will collect information on the processes, outcomes, and cost of care to appreciate the value of surgery in treating spine conditions. Outcomes will be assessed based upon hospital metrics (length of stay, readmissions, adverse event occurrence), patient satisfaction (clinic outpatient metrics such as Press Gainey scores), and outcomes assessments (EQ-5D, ODI, VAS scores recorded pre- and post-operatively).  On-going quality improvement efforts will focus upon these metrics, as captured and presented in a clinician-specific dashboard format.

Value is defined in different ways depending on the audience. Physicians may be interested in cost-versus-health benefit; payers may be interested in cost-benefit analysis, including cost of avoided downstream healthcare costs; employers may be interested in median days to return to work and/or employee productivity while at the place of employment; patients and caregivers may be interested in functional status or health-related quality of life.  The Stanford Spine Database will collect data of interest to multiple audiences.  Improving internal systems and realizing quality improvements will be fostered by capturing a variety of outcome metrics.

Today’s healthcare environment sees, appropriately, an increasing attention paid to health care costs and patient outcomes. Spinal conditions represent a substantial portion of healthcare costs. A 2002 survey of U.S. adults found that 14% reported neck pain and 26% reported low back pain in the previous three months (Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31(23):2724-2727). Martin et al., 2008 note that low back pain alone accounts for approximately 2% of all physician office visits and that only routine examinations, hypertension, and diabetes results in more office visits. Neck and back disorders have been estimated to cost $86 billion annually (in 2005 dollars). Spinal-related costs are high relative to other health conditions; the National Heart, Lung, and Blood Institute estimated the cost of cancer care at $89 billion in 2007 (NHLBI factbook: direct and indirect costs of illness by major diagnosis, U.S. 2006. National Heart, Lung and Blood Institute Web site. http://www.nhlbi.nih.gov/about/factbook/toc.htm. Accessed May 18,2007

Recent documents such at the Health Technology Assessment of Cervical Spinal Fusion for Degenerative Disc Disease commissioned by the Washington State Health Care Authority are likely harbingers of future efforts by payers to limit costs for expensive spinal surgeries. As data to properly evaluate the cost-versus-health-benefit of spinal surgery relative to other treatment options are not available in the literature, it becomes increasingly important for Stanford to collect its own data in order to be a leader in creating the evidence base for the value of spinal surgery.  To respond to payers seeking to limit healthcare spending on spine care, clinicians must demonstrate the clinical efficacy and quality of spine interventions.

Data will be collected on patients seen at Stanford, both pre-treatment and post-treatment, in order to assess change in spinal condition that can be allocated to treatment. This information can be used for marketing and referral purposes. Data will also be collected on the processes of care (e.g., type of surgical approach, type of implant, level of rehab, etc); these data on the process of care will be linked to data on the outcomes of care. This type of information will be used to identify opportunities for quality improvement and to improve the practice of clinical care at Stanford Hospital and Clinics.  With appropriate IRB approval, these effects may also be published in the peer-reviewed literature.

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