How do validated measures of functional outcome compare with commonly used outcomes in administrative database research for lumbar spinal surgery?

Clinical interpretation of health services research based on administrative databases is limited by the lack of patient-reported functional outcome measures. Reoperation, as a surrogate measure for poor outcome, may be biased by preferences of patients and surgeons and may even be planned a priori. Other available administrative data outcomes, such as postoperative cross sectional imaging (PCSI), may better reflect changes in functional outcome. The purpose was to determine if postoperative events captured from administrative databases, namely reoperation and PCSI, reflect outcomes as derived by validated functional outcome measures (short form 36 scores, Oswestry disability index) for patients who underwent discretionary surgery for specific degenerative conditions of the lumbar spine such as disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis. After reviewing the records of all patients surgically treated for disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis at our institution, we recorded the occurrence of PCSI (MRI or CT-myelograms) and reoperations, as well as demographic, surgical, and functional outcome data. We determined how early (within 6 months) and intermediate (within 18 months) term events (PCSI and reoperations) were associated with changes in intermediate (minimum 1 year) and late (minimum 2 years) term functional outcome, respectively. We further evaluated how early (6–12 months) and intermediate (12–24 months) term changes in functional outcome were associated with the subsequent occurrence of intermediate (12–24 months) and late (beyond 24 months) term adverse events, respectively. From 148 surgically treated patients, we found no significant relationship between the occurrence of PCSI or reoperation and subsequent changes in functional outcome at intermediate or late term. Similarly, earlier changes in functional outcome did not have any significant relationship with subsequent occurrences of adverse events at intermediate or late term. Although it may be tempting to consider administrative database outcome measures as proxies for poor functional outcome, we cannot conclude that a significant relationship exists between the occurrence of PCSI or reoperation and changes in functional outcome

Improving access to emergent spinal care through knowledge translation : an ethnographic study

Background: For patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery. Methods: An ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario’s call centre. Results: Several themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation. Conclusions: Our findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts

Referral Practices for Spinal Surgery are Poorly Predicted by Clinical Guidelines and Opinions of Primary Care Physicians

BACKGROUND: Degenerative disease of the lumbar spine is common. Although surgery can benefit selected patients, variation in surgical referrals reduces overall access to care. OBJECTIVES: To compare the actual referral practices for patients with degenerative disease of the lumbar spine with recommendations for surgical referral based on clinical practice guidelines (CPGs) and family physician (FP) opinions. RESEARCH DESIGN: An expert panel of primary and specialist physicians, using a Delphi process, came to a consensus on referral recommendations from CPGs based on a series of clinical vignettes. The vignettes were also presented to practicing FPs in Ontario, Canada, to determine their preferences for (or likelihood of) referral. SUBJECTS: We assembled a 10-member multispecialty expert panel. Practicing FPs were randomly sampled, stratified by county, and their patients were sampled purposefully by the FP. MEASURES: Respondents, both panelists and FPs, were asked to rate the appropriateness of surgical referral for a series of clinical vignettes. Patients reported their clinical symptoms and whether they had been referred to a surgeon. Using random-effects probit regression, predictions were compared with actual referral. Receiver operating characteristic curves were constructed and area under the curve (AUC) was measured. RESULTS: Consensus of the panel on recommendations for referral was achieved after 2 iterations (Cronbach alpha = 0.96). Based on responses from 107 patients and 61 FPs, we found poor concordance of both predicted FP preferences (AUC 0.57) and CPG recommendations (AUC 0.64) with actual referral. CONCLUSIONS: Referral practices are poorly predicted by CPG recommendations and individual FP opinions, based on clinical factors. Understanding other nonclinical factors may be more important in reducing variation in referrals and improving access

Referral Practices for Spinal Surgery are Poorly Predicted by Clinical Guidelines and Opinions of Primary Care Physicians

BACKGROUND: Degenerative disease of the lumbar spine is common. Although surgery can benefit selected patients, variation in surgical referrals reduces overall access to care. OBJECTIVES: To compare the actual referral practices for patients with degenerative disease of the lumbar spine with recommendations for surgical referral based on clinical practice guidelines (CPGs) and family physician (FP) opinions. RESEARCH DESIGN: An expert panel of primary and specialist physicians, using a Delphi process, came to a consensus on referral recommendations from CPGs based on a series of clinical vignettes. The vignettes were also presented to practicing FPs in Ontario, Canada, to determine their preferences for (or likelihood of) referral. SUBJECTS: We assembled a 10-member multispecialty expert panel. Practicing FPs were randomly sampled, stratified by county, and their patients were sampled purposefully by the FP. MEASURES: Respondents, both panelists and FPs, were asked to rate the appropriateness of surgical referral for a series of clinical vignettes. Patients reported their clinical symptoms and whether they had been referred to a surgeon. Using random-effects probit regression, predictions were compared with actual referral. Receiver operating characteristic curves were constructed and area under the curve (AUC) was measured. RESULTS: Consensus of the panel on recommendations for referral was achieved after 2 iterations (Cronbach alpha = 0.96). Based on responses from 107 patients and 61 FPs, we found poor concordance of both predicted FP preferences (AUC 0.57) and CPG recommendations (AUC 0.64) with actual referral. CONCLUSIONS: Referral practices are poorly predicted by CPG recommendations and individual FP opinions, based on clinical factors. Understanding other nonclinical factors may be more important in reducing variation in referrals and improving access