Published on the Sept. 26, 2016, Rheumatology Network website
By Whitney L. Jackson
For many patients – especially those facing spinal surgery – the specter of an unknown outcome can be frightening. Knowing their odds for a successful procedure versus a failed operation can help many individuals decide whether and what type of surgery they’d like to undergo.
And, having the data to determine those success percentages can also help surgeons and other providers make the right decisions when it comes to expenditures and recouping reimbursement.
Using this data is called predictive modeling. To understand how its affected spinal surgeries and payments associated with it, Rheumatology Network spoke with Joseph Osorio, M.D., Ph.D., a resident with the Department of Neurological Surgery at the University of California at San Francisco, about his study, “Predictive Modeling of Complications,” published recently in Current Reviews in Musculoskeletal Medicine.
Rheumatology Network: Why did you decide to study predictive modeling? What is the importance of this tactic?
Dr. Osorio: The importance really lies with the patients we operate on most frequently. It’s complex spine surgery. Patients are prone to having complications because their surgeries involve many levels, and there’s a high risk for complications. Patient satisfaction is something that we want to do well, and we wanted a tool where we could use all the data at our disposal in our practice in the clinic to give them a number they could understand. For example, they’ll have an 85 percent chance of success rather than telling them patients like them generally do well with this operation.
One of the benefits we have is the professional societies are collecting data the way we’ve been doing here at UCSF and at other centers that focus on adult spinal deformities. We have a repository of data and collect large volumes, prospectively, on patients that fall within the adult degenerative and scoliosis parameters set out in the literature. We put that information into a database and go back, retrospectively, and analyze it. There’s a huge wealth of information there to benefit us. Part of the nuts and bolts of predictive modeling is having quality data and having large volumes of it. If you don’t have quality data, then it is a limitation to the predictive model. If you do, you can apply these techniques to other conditions and settings, and achieve the same success that we have.
Rheumatology Network: How impactful has the modeling been on spinal surgery?
Dr. Osorio: I think it’s been extremely useful with aging individuals and those undergoing revision surgery. Some of them want to know because they have many options for surgery. Do they go with the larger surgery that may address the bigger problem of global spinal balance, or do they choose a less invasive one that might have a likelihood for needing another spine surgery because the bigger problem was not addressed? Are they someone who doesn’t want to take the risk of undergoing such a big operation? With this data, we can relay possible outcomes to the patient.
Rheumatology Network: What were your main findings? Why are they important?
Dr. Osorio: Some of the main findings started with one of our initial pieces of work. The first one looked at surgical complications in the adult spinal deformity patients. Those were patients we did large segment fusions on, and they returned with adjacent level disease. They come back with new pain or new neurological indications, and they need another operation. In some sense, they’ve failed the surgery and are in need of a revision operation. We were able to take 500 or so patients and look at those we had two-year follow-up data on. We look at X-rays and clinical information and we’re able to say which of all those patients — if we throw in a series of variables — are going to come back with a failed surgery. We added in variables that were strong predictors — some were based on radiographic parameters that are commonly used in the clinic to assess adult spinal deformity patients. From previous studies, we predicted that these parameters, including being over age 64, being sagittally imbalanced, and having flat back syndrome where patients develop much of their back pain by overuse of compensatory muscles, are important ones to monitor.
Rheumatology Network: Did you find anything unexpected?
Dr. Osorio: It wasn’t unexpected, but it is something that gets discussed in the literature a great deal. It’s where do we stop — at what level do we end? Do we go to the pelvis or the sacrum? Does it make a difference or not? Surgeons want to know. It seems that it does make a difference, but we need to do more studies to get a better sense of it all. At our institution, we commonly end our large spine surgeries at the pelvis. That’s something that seems to be coming out in the predictive model.
Rheumatology Network: Are there any challenges to spinal surgeries that were revealed?
Dr. Osorio: I think the biggest challenge with studies like this is that when we see patients in our clinic, we really do have an algorithm for the way we analyze each patient. Everyone receives a standing 36-inch long X-ray. We’ve essentially designed our clinic that way – we don’t see patients until they get that X-ray, so that might be a challenge for other providers who are not using this film as one of their tools in understanding a patient’s global alignment. If you start reading the literature now, you get the sense that all of us are using 36-inch X-rays to identify parameters that are important for choosing whom to operate on. In many cases, when we receive referrals from the community to see patients who have had a failed surgery, there often isn’t a record of having had a 36-inch X-ray acquired. Providers often obtain a CT scan, or an MRI of the lower back, but overlook the global alignment. We’re looking at global alignments, but the challenge in moving forward is that providers aren’t looking at the problem in a global way. We’re trying to move the field in that direction — to get providers to understand that patients often have problems that could impact more than one region. They need to think about the patient and the spine as a whole.
Rheumatology Network: How does this work fit in with MACRA?
Dr. Osorio: I would say as we move forward with this wealth of information, we’re moving toward having an abundance of information from our use of electronic heath records. Having access to this data, we’re going to have a better understanding as to what parameters most impact surgical outcomes. We can better justify an expected outcome. Are providers, when they’re offering surgeries, looking at other providers’ outcomes to get a sense as to how the field is adapting/improving? Are they actually at the mean or are they below average? Are more of the patients they’re providing surgeries to, patients they would’ve know might have failed if they’d looked at a set of high risk targets? We can provide them with these targets. We can educate providers that are going to be doing do this level of spine surgery, to pay close attention to these targets. Counsel them that it will impact their success. I think overall, MACRA is going to really try to differentiate providers that are given that kind of data and incentivize them to provide high value care. Those that are below the mean are going to suffer. This will provide them with a tool and give them a better understanding of what success is in this field.
Rheumatology Network: How can this work be used to promote better care and outcomes?
Dr. Osorio: One of the challenges we fall into, is justifying and providing large scale operations at tertiary and quarternary care centers. Operations are expensive. Smaller spine surgeries can offer immediate improvement, but if you don’t think about addressing the larger scale problem, the patient will suffer and they might be back within a year with a failed operation. This will result in the patient requiring another operation, which is something we see very often. So, in order to justify doing a larger cost operation up front, it helps to be able to look out several years in advance and predict outcomes. If you tell someone justifying cost that reimbursement for an operation is X dollars more than a smaller-scale operation, they will likely want evidence through data about why spending that much more can be justified. If they are looking at larger operations that are chosen based on the correct indications, they’ll realize over the long term that most patients aren’t returning for an initial failed surgery. In this ideal scenario, the cost is better justified for the larger operations because you need fewer surgeries overall. Ultimately, through these kinds of examples you can get an understanding how these large scale operations are justified.
I think, overall, predictive modeling and analyzing is something that’s used in the business and government worldwide. We’re simply applying it to healthcare now. We’ve been stuck in this more traditional statistical model, that is hindered because of the fundamentals that require hypotheses and assumptions. They answer a single question, but really now that we’re having an abundance of data, we’re able to better answer any questions that are patient specific and individualized to a particular problem. We can provide a number that’s easier for a patient to interpret. It’s hard to interpret an odds ratio when making a decision as to what surgery to have, but if I say you have a 96 percent chance of doing well from this surgery, that number is something that makes sense.
To read the article at its original location: http://www.rheumatologynetwork.com/news/predictive-modeling-spine-surgeries-macra-era
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September 28, 2016
Posted by wjpalmer |
Healthcare | Joseph Osorio MD PHD, MACRA, spine surgery predictive modeling |
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Published on the Aug. 15, 2016, Rheumatology Network website
By Whitney L.J. Howell
For patients with hip and knee osteoarthritis, total arthroplasty is a relatively common procedure. To date, however, no official best practice recommendations exist for post-operative rehabilitation and physical therapy services.
To clear up any confusion, Marie Westby, PT, Ph.D., from the University of British Columbia, surveyed two expert panels, including U.S. and Canadian clinicians, researchers and patients, in a three-round online Delphi survey. They offered their input on how best to proceed with maximizing and optimizing a patient’s condition post-surgery. The result was 22 best practices for total hip arthroplasty and 24 for total knee arthroplasty.
Overall, survey participants pointed to the need for supervised rehabilitation interventions provided by trained health professionals within the first two post-surgical years. However, no consensus emerged on the specifics of how these services can best be provided.
Ultimately, though, Dr. Westby said, the survey outcome is a strong step toward reducing practice variation, closing the evidence-practice gap, and improving rehabilitation service quality. Rheumatology Network spoke with Westby about the implications of her study and the impact it could have on reimbursement in the MACRA environment.
Rheumatology Network: Why did you decide to look into best practices for total hip and knee arthroplasty?
Dr. Westby: As a physical therapist, I provide rehabilitation services after hip and knee replacement surgery. I noticed the amount of variation in care and the different outcomes patients experienced. It started with a survey I conducted across our province in British Columbia more than 15 years ago. I was shocked by the variety of care. That’s when I decided to go back to school to formalize my research training in order to standardize or identify what the best practices are for hip and knee replacement rehabilitation.
What I saw ranged from patients having joint replacement and being discharged from the hospital with some rehabilitation or physical therapy services or they didn’t know they were supposed to receive anything or they have a really nice well-coordinated program in the community where they know what to expect. In those cases, patients start a formal rehabilitation program within a week from surgery, they’re followed for 8-to-12 weeks, and it’s a comprehensive program with excellent communication. It varies in British Columbia because we don’t have the high volume of patients that exist in the United States, so we don’t do a lot of procedures. There are fewer well-established programs. But, some places, like Vancouver does hundreds of joint replacements a year, so they have those well-established programs in place.
I was concerned that even the most basic rehabilitation wasn’t being offered to patients even in the forms of tele-rehab or single-visit follow-up care.
Rheumatology Network: Why does identifying best practices matter?
Dr. Westby: From the patient perspective, so much is invested in the surgery itself in terms of the cost regardless of which healthcare system they’re in. So much is put into it, and rehabilitation is a fraction of the overall cost. Patients tell us, and I’ve seen this over 25 years of practice that rehabilitation does make a difference in the overall recovery because they’ve lived with osteoarthritis or another arthritis form in their knee or hip for a decade or more. The surgery itself, while it relieves pain, restores motion, and makes improvements in basic function, still leaves a lot of problems with walking, muscle weakness and balance. Only with appropriate rehabilitation are people able to return to sports or exercise. Patients invest a lot and undertake risk to do it. I think they and the healthcare system need to invest similar amounts into their ultimate recovery. We need to optimize the outcomes. With the surgery itself, you get between 75 percent and 80 percent of the outcome of the process. The extra 20 percent to 25 percent is achieved with appropriate rehabilitation. It would be a shame to under-reach and the patient never reach their full potential.
From the provider perspective, all licensed healthcare personnel are ideally providing services and interventions that are evidence based. Best practices haven’t been identified before. People aren’t actually sure of the appropriate timing or location or type of treatment and intervention and assessment that should be done. We all want to provide the best care possible that is evidence based so that we can be effective. In many cases, that will allow us to be more efficient and save dollars. That connection between best practices and cost savings has been established in other areas. The literature, though, that we have to work with in hip and knee replacements is weak. It would be nice to know that we’re providing effective care at a reduced cost.
Rheumatology Network: What are the most important parts of your results? What are their impacts?
Dr. Westby: The most important thing is the strong support for the need for structured and supervised rehabilitation by all of the experts in the survey panel. The panel, as a whole, agreed it’s necessary, but there was no agreement on timing or location for where the services should be rendered. It helps patients prepare for the experienced if they know what’s in place after surgery. They’ll know what to look for.
The work I’ve gone on to do deals with the minimum standards of care based on quality indicators. Patients are better able to monitor their own care and can prepared to be more engaged. They can look for providers who offer similar levels of care so they don’t have to be as concerned about the specific provider from whom they receive care. Supervision can be through the telephone or video, or it can be a follow-up visit one time to the clinic.
There are different ways to do it. It doesn’t always have to be once or twice a week in the office. Patients just need to know that there’s someone there to answer their questions in a timely manner if they have any because there’s very little contact with the surgeons after the procedure is complete. Maybe there’s a 3-to-6 week visit and a 6-to-12 month visit. Really, it’s the physical therapy and rehabilitation provides to offer the interim educational support and answers to questions in the immediate post-operative period.
Rheumatology Network: Was there anything unexpected in your findings? Anything that could present a challenge?
Dr. Westby: Something that really came out – that I’m glad to see – is that the literature is addressing the contextual issues that impact rehabilitation care and outcomes. Some of those issues have to do with the patients themselves and their own general health, anxiety, depression and the kind of medical coverage they have. I found it interesting that regardless of what role the survey panelist played – research, clinical, surgeon or physical therapist – they really recognized how important it is to consider the personal and external factors when looking into what kind of rehabilitation services or outcomes you can expect. And, the larger registries are starting to collect this information, as well.
Based on an analysis of survey panelists responses compared to patient response. It was evident that there’s variability between the experts about what they thought was important about the right timing and appropriate provider for rehabilitation services, as well as what the appropriate setting would be. Even though they came to a consensus about the need for supervised services, their views differed in other aspets of joint replacements.
I was surprised about the timing. They really couldn’t come to an agreement about whether rehabilitation for knee and hip replacement should start right away after the hospital discharge or to wait several weeks. There was a lack of consensus around the setting. They couldn’t come to an agreement, and that’s actually a good thing. It shows that rehabilitation services can be provided in a variety of settings and one isn’t necessarily better than the other.
One of the things I’m working on with colleagues is trying to define the minimal dosage in terms of rehabilitation. The panel didn’t come to an agreement on how many days a week or for how many hours a session rehab should go one. Nor did they decide the intensity. And, that’s how payments are determined. They’re often made based on the number of visits. Many extend out to 90 days post-discharge, but it’s never been established that 90 days is the ultimate rehabilitation dosage for hip and knee replacement. It’s ranged anywhere from less than 3-to-4 weeks to up to 20-to-24 weeks. It’s surprising and frustrating because those numbers and dosages are what payments for services are based on.
Rheumatology Network: How does this research fit in with MACRA and changing reimbursement policies?
Dr. Westby: I think it’s going to be the follow-up on the most recent work with quality indicators that’s going to make the difference. Expert opinion is considered low-level evidence. Now, we can take that and move forward to identify quality indicators that are true measurements that will reflect the standard of care. They will be used to provide care within the bundled payment approach in terms of letting providers know what they should monitor and report on.
Rheumatology Network: How can your work be used to promote better and improved outcomes?
Dr. Westby: The project I’m working on now is to develop two separate tool kits. The first is for patients and family members to help them understand the quality indicators so they now have a minimum standard of care that they know they should receive. It helps them understand how to use the indicators to engage in their own care and discuss it with providers. And, in some circumstances, it might help them identify a provider to go to. If they have the choice within the community to see one private practice or another, patients can look at measurement indicators and see what the practice is reporting on. What do they make available on their website? How can the patient use that information to make an informed decision?
The other tool kit is for the healthcare professional, and it develops tools that are ideal for therapy and rehabilitation purposes. It can be used at the point of care for real-time decision making. Right now, most quality indicators come from data collected from electronic medical records or registries or questionnaires conducted after the fact. Data from questionnaires doesn’t help because it’s not collected in real time. It’s responsive, and the patient can’t benefit from it.
In Canada, we don’t have pay-for-performance, but it might be coming. Regardless, private practices can monitor their data to help them fill in the gaps when they aren’t doing well in certain areas. They can take those measurements and do a quality improvement programs, address the problems, and find some areas where they can create better outcomes. Many multi-site clinics can find the ones that aren’t performing as well as the others. Maybe they aren’t seeing as many patients, and they could identify ways to increase patient volume or reduce costs. It can be used for marketing purposes. If they’re willing to look at where they have gaps and possibly aren’t performing well, they can make improvements.
Rheumatology Network: What do you see as the next steps?
Dr. Westby: I’m really focusing on physical therapy and encouraging providers to get involved in the whole process in both the United States and Canada. If they don’t have a say in which measures are included or acceptable for the quality reporting used to support bundled care, then the ones that are selected as measures, they might find aren’t applicable to them or they’re just not feasible Or, perhaps they don’t really guide practice. And, the ultimate downside is that this affects their remuneration. Providers really need to have a say in what’s chosen. They need to participate in forums and meetings where people are selecting which measures to use.
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August 18, 2016
Posted by wjpalmer |
Healthcare | MACRA, Marie Westby, rheumatology rehabilitation, total hip arthoplasty rehabilitation, total knee arthroplasty rehabilitation |
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Whitney Palmer 