Boos, Norbert

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Norbert Boos Outcome assessment and documentation:a friend or foe?Received: 30 October 2005Published online: 29 November 2005 Springer-Verlag 2005In all European countries, the ever-raising healthcare costs prompt dis-cussions on rationalization andreallocation of resources. Restric-tions in the application of variousmedical treatments have already be-come reality, for example, in Swit-zerland, where the implantation ofdisc arthroplasty and kyphoplastyhas been regularized by the govern-ment. As a result, a nation-widequality control for the use of theseemerging technologies had to beimplemented prior to further reim-bursement by health insurers.The treatment of spinal disordersis becoming more and more tech-nology driven rather than beingbased on scientiﬁc evidence. It ap-pears that the gap between clinicalpractice and scientiﬁc evidence israpidly opening up. However, thelack of scientiﬁc data demonstratingthe eﬀectiveness of various forms ofspinal treatment [6] may have asubstantial and detrimental impactin the near future when debates onreallocation or restriction of health-care resources further arise. In someareas, such as spinal fusion, it is al-ready argued that this techniqueshould be a case of restraint [1].Spinal surgery is predominantlyfocusing on the improvement ofhealth-related quality of life and inmost cases is not a life-saving inter-vention. By virtue of this, the treat-ment of the vast majority of spinaldisorders is theoreticallydispensable.It appears mandatory that theEuropean Spine Journal, as the oﬃ-cial publication of the Spine Societyof Europe, take a leading role instipulating the generation of con-vincing scientiﬁc evidence of notonly the eﬀectiveness but also thecost-eﬀectiveness of various treat-ment modalities. As a prerequisite,improved knowledge in the ﬁeld ofoutcome assessment and documen-tation is necessary. In recent years,much research eﬀorts were directedto develop and evaluate appropriateinstruments to assess outcome.Meanwhile consensus among clini-cians and researchers has beenreached regarding the use of theclassic subjective and objective singlerating scale ‘‘excellent, good, fairand poor’’ being insuﬃcient for avalid, reliable and comparable out-come assessment. Nevertheless,many clinicians are confused aboutwhat type of outcome assessments isthe most important and whichquestionnaires are best suited forclinical investigations, quality con-trol or benchmarking. It is theobjective of this special issue toprovide an up-to-date overview onthe current knowledge in the ﬁeld ofoutcome assessment of spinal disor-ders, which may serve as a referencebase to researchers and clinicians.The prerequisite for understand-ing research articles on the treat-ment outcome of various spinalprocedures is a thorough under-standing of the methodologicalprinciples, which will determine thelevel of generated scientiﬁc evi-dence. As an introduction, Hiebertand Nordin highlight in their articlethe methodological aspects thatdetermine high-quality research.This knowledge allows for a criticalreview of articles in this ﬁeld and todecide on the eﬀectiveness of thecorresponding treatment.The subsequent papers focus onthe four key elements that constitutethe basics of a comprehensive out-come assessment, i.e. pain,back-related compromise of physicalfunctioning, work-related outcomeand health-related quality of life.Pain is the most predominate indi-cation for the treatment of spinaldisorders and therefore outcomeassessment must concentrate on thisparameter. Haefeli and Elferingprovide an overview on the currentstatus of pain assessment and discussEur Spine J (2006) 15: S1–S3DOI 10.1007/s00586-005-1055-7 EDITORIALN. BoosCenter for Spinal Surgery,University of Zurich, Balgrist,Forchstrasse 340, 8008 Zurich, SwitzerlandE-mail: Norbert.boos@balgrist.chTel.: +41-44-3861270Fax: +41-44-3861609tools for a minimum and a morecomprehensive assessment. Mu¨lleret al. summarize the current litera-ture on the six most widely used,condition-speciﬁc, self-administeredassessment questionnaires for low-back pain and discuss the strengthand weaknesses of these instru-ments. In the treatment of backdisorders only 15% of the costs aregenerated by the actual treatmentwhile 85% are related to indirectcosts resulting from compromisedwork capacity, lost work days andearly retirement. Elfering thereforehighlights the importance of thework-related outcome assessment,reviews work-related outcome mea-sures currently in use and discussesthe validity of theses measures.Health is an essential part of qualityof life and spinal interventions oftenaim to improve this quality of life.Nemeth describes some commonlyused health proﬁle instruments andhighlights that preference-basedinstruments will become more andmore important when quality-ad-justed life-years are calculated incost-eﬀectiveness analysis.Although randomized controlledtrails will remain the gold standardfor a scientiﬁc comparison of two ormore competing treatment modali-ties, this study design is not univer-sally applicable, is very timeconsuming and requires consider-able resources. Some researchquestions can only be addressed byvery large data. In this context,large observational data collections,i.e. registries, will come into the fo-cus of outcome research. Roederet al. provide conceptual argumentsfor the need of a European spineregistry such as the SSE SpineTango [7]. Fritzell and co-workershighlight the obstacles of imple-menting such a registry and reportpractical solution as exempliﬁed bythe Swedish Spine Registry.The next series of articles providean up-to-date overview on the cur-rent state of scientiﬁc evidence onconservative and operative treat-ment outcomes, which is based onthe work by the Cochrane group.The two articles by van Tulder andco-workers provide an excellentoverview and should help to focusfuture outcome research on areaswhere scientiﬁc evidence is mostneeded to improve patient care inclinical practice. Failure in surgicaltreatment substantially adds to theenormous costs of back-relatedproblems. Mannion and Elferingfocus, in their review, on the psy-chosocial predictors of outcome,which may be helpful for clinicaldecision-making in daily clinicalpractice and have substantial impacton treatment outcome.Thus far, outcome research haspredominantly focused on the abil-ity of a treatment modality toreduce pain and improve the func-tional status of the patient withspinal disorders. Today, clinicaleﬀectiveness does not suﬃce in thelight of limited heath care resources,and economic evaluations will be-come a genuine part of future out-come assessments. The objective ofthe article by Van der Roer et al. isto provide an overview of the cur-rent views on economic evaluationsand to help clinicians to betterunderstand and interpret resultsfrom these studies.The primary goal of this specialissue is not to overwhelm the readerwith facts and innumerableoutcome instruments. The intentionis to guide the reader throughoutcome assessment and help thereader to separate importantaspects from less important aspects.In the ﬁnal article, Grenough sum-marizes this special issue andprovides practical guidelines on theindication and practical use of thevarious outcome tools for busyclinical practice.Very recently, the adverse eﬀectsof outcome research have becomemore apparent. In many hospitals,a patient is overwhelmed withcompleting questionnaires that hereceives from physicians, nursingstaﬀ, hospital administration andgovernmental institutions, whichresults in incomplete and unreliabledata sets owing to the reluctance ofthe patient to ﬁll in all thesequestionnaires. Following thedevelopment and introduction ofoutcome tools for the variousaspects of treatment, one mustnow consider what is really neededto improve patient care. It is nothelpful if the data collected endsup in a data cemetery. The goldenrule of ‘‘less is more’’ alsoapplies to outcome assessment.Our next goal must be to simplifyoutcome assessment to a minimalacceptable question set whichneeds to be validated also withregard to cross-cultural aspects.This trend is reﬂected in recentpublications [4, 5] and upcomingstudies [2, 3].My personal perspective andhope is that the European spinalcommunity will manage, in the nearfuture, to reliably and validly assessthe outcome of spinal interventionsby only a few questions includingeconomic aspects, which will allowsus to decide not only on the clinicalbut also on the economic eﬀective-ness and beneﬁts of various treat-ment modalities. If we succeedoutcome research and documenta-tion will be a friend and not a foe ofclinicians and patients.S2References1. Deyo RA, Nachemson A, Mirza SK(2004) Spinal-fusion surgery—the casefor restraint. N Engl J Med 350:722–7262. Haefeli M, Elfering A, Aebi M, Boos N(2005) What comprises a good outcomein spinal surgery?—A preliminary surveyamong spine surgeons of the SSE. EurSpine J 14(Suppl 1):S593. Hagg O, Fritzell P, Nordwall A (2005)Simplify outcome measure. Eur Spine J14(Suppl 1):S184. Hagg O, Fritzell P, Oden A, Nordwall A(2002) Simplifying outcome measure-ment: evaluation of instruments formeasuring outcome after fusion surgeryfor chronic low back pain. Spine27:1213–12225. Mannion AF, Elfering A, Staerkle R,Junge A, Grob D, Semmer NK, Jacobs-hagen N, Dvorak J, Boos N (2005)Outcome assessment in low back pain:how low can you go? Eur Spine J (onlineﬁrst)6. Nachemson AL, Jonsson E (2000) Neckand back pain. The scientiﬁc evidence ofcauses, diagnosis adn treatment. Lippin-cott Williams & Wilkins, Philadelphia7. Roder C, Chavanne A, Mannion AF,Grob D, Aebi M (2005) SSE SpineTango—content, workﬂow, set-upwww.eurospine.org—Spine Tango. EurSpine J (online ﬁrst)S3

Outcome assessment and documentation: a friend or foe?

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Outcome assessment and documentation: a friend or foe?

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