CINCINNATI—By tracking the outcomes of more than 5,000 neurosurgical procedures they performed in 2009, physician researchers at the University of Cincinnati (UC) and the Mayfield Clinic have shown that such data can be successfully gathered and that processes for measuring outcomes can be established to improve surgical outcomes and quality.
The results were published online this month in the Journal of Neurosurgery.
"Health care reform has included discussions about surgical outcomes,” says Philip Theodosopoulos, MD, associate professor of neurosurgery at UC and a neurosurgeon at the Mayfield Clinic, the clinical affiliate of the neurosurgery department. "Yet these outcomes can be difficult to measure in a clinical practice, outside the realm of clinical trials. Our goal was to take an important step forward in developing a process for measuring outcomes that is accurate, comprehensive and auditable.”
By tracking outcomes, the department of neurosurgery and the Mayfield Clinic, hoped to promote quality of care and better decision-making while establishing data that would be helpful for patients, families and health care providers. An electronic medical records system (EMR), first implemented by Mayfield in 2005, helped facilitate the gathering, interpreting and reporting of data. Information gathered during each patient interaction was recorded into the EMR by physicians, nurses, medical secretaries and medical assistants.
"This large study has yielded many lessons that bear on the development and implementation of a process that can be generalized for many medical settings,” says Theodosopoulos, the study’s principal investigator.
The initiative, undertaken as a feasibility study and dubbed the Outcomes Project, involved assessment of 5,361 consecutive elective and emergency surgical cases by 19 neurosurgeons at multiple hospitals.
Outcomes were based on the health and functional status of patients immediately after surgery and at later post-operative periods. Data was tracked in the following categories:
• Length of hospital stay.
• Major and minor complications.
• Return to work.
• Symptom severity.
• Scores by validated scales, including the Oswestry Disability Index for patients with spinal disease; the Karnofsky Performance Scale and Eastern Cooperative Oncology Group Performance Status for patients with tumors; and the modified Rankin Scale for patients with vascular conditions and trauma.
Following a one-year trial period (2007 to 2008) that involved three technologically savvy neurosurgeons, the Outcomes Project was rolled out across the organization in 2009. Preparation included practice-wide data-collection training for staff.
One of the project’s achievements, Theodosopoulos says, was the documented trend toward improved and more accurate noting of complications into the EMR field as the project progressed. Reporting rates of major complications improved throughout the year, from 81 percent in the first quarter to 90 percent in the fourth quarter. In auditing, rates of unreported complications decreased from 11 percent in the first quarter to 4 percent in the fourth quarter.
In publishing the results, the researchers stated that complication rates were available for 4,593 procedures, of which two-thirds were spinal and one-third cranial. Of these, no complications were reported for 4,367 procedures, or 95 percent of the total. Major complications included culture-proven infection in 0.6 percent, cerebrospinal fluid leak in 0.9 percent, repeat surgery during the same hospitalization in 0.4 percent and new neurologic deficit in 0.8 percent.
In other outcomes:
• Of the 5,361 patients treated, 86 percent were discharged home; 9 percent went to a rehabilitation center; 3 percent went to a nursing home; and 0.76 percent died.
• Procedure-specific median length of hospitalization was three days for a craniotomy for aneurysm and tumor, and less than one day for an angiogram, anterior cervical discectomy with fusion, or lumbar discectomy.
"The Mayfield Clinic has frankly documented its efforts during the process of collecting outcome data in this journal article,” Theodosopoulos says. "The article highlights the lessons learned during implementation and auditing, and it is the largest series to report on consecutive patient outcomes collected prospectively at every a point-of-care interaction and audited for accuracy.
"This is a major step forward in methodology of outcomes reporting, something that people doubted for a long time could be done—particularly in surgery—and we could say we certainly proved the doubters wrong.”
Co-authors of the article are Andrew Ringer, MD, Christopher McPherson, MD, Ronald Warnick, MD, Charles Kuntz IV, MD, Mario Zuccarello, MD, and John Tew Jr., MD. All are faculty members in the department of neurosurgery, Mayfield Clinic neurosurgeons and members of the UC Neuroscience Institute, which is affiliated with the UC College of Medicine and UC Health.