A program of risk stratification to more judiciously select candidates for adult spinal deformity surgery more selectively can yield reduced complications and increased cost effectiveness, according to Rajiv Sethi, MD. Dr. Sethi presented the results of such a program during a 2017 Scoliosis Research Society Specialty Day session.

"The number of operative adult scoliosis cases has increased significantly, and we have to find a better way to care for these patients at lower cost," he said. "The operation has to last for a defined period to be cost effective based on current standards in quality of life years (QALYs) and how much we want to pay for each QALY."

Dr. Sethi noted that payment for spinal surgery is under increasing scrutiny. "Because physicians are not driving the reform, the companies that insure large numbers of these patients are stepping in to do so," Dr. Sethi said. He and his colleagues at Virginia Mason Medical Center in Seattle have published a novel algorithm on how to provide adult spinal deformity care more efficiently and effectively through risk stratification and standardization in care delivery. The Seattle Spine Team (SST) approach has demonstrated a significant risk reduction since it was implemented, resulting in a three-fold reduction in re-admissions and a 12-fold decrease in return to surgery in the first year.

The SST approach is based on the following cornerstones:

• Case presentations are made to and approved (or denied) for surgery by a live multidisciplinary spine conference.
• Patients are required to complete a patient education course in preparation for surgery and on postoperative care.
• The surgery is performed by two attending surgeons, one trained in neurosurgery and the other in orthopaedic surgery. A standardized intraoperative protocol, without case-to-case variability, is followed.

In general, current complication rates are "sobering," Dr. Sethi said. Studies have shown complication rates in spinal surgery ranging from 10 percent to 86 percent. From a payer's perspective, this wide variation is not sustainable.

The risk stratification approach addresses flaws in the current system by establishing a multidisciplinary care model for "choosing the best patients and mitigating risks," he explained. Much of the strategy involves "knowing when to say 'No,'" along with the building of a "complex spine team that consists of 'complex spine'–specific anesthesia and medicine and, for example, two attending surgeons for three-column osteotomies and an intraoperative protocol to track coagulopathy and blood loss."

From assembly line to the OR
The system adopted in Seattle, Dr. Sethi said, is actually an adaptation for medicine of Improvement Pathways developed by the carmaker Toyota. As applied to spine surgery, the SST uses a risk-flow map with a convergence of standardized pathways addressing intraoperative, short-term, and long-term complications.

The adoption of a standardized pathway is a matter of "understanding the current state of spine surgery and how to improve on that state and reinvent our services," Dr. Sethi said. "This means adopting 'standard work' and reducing variability, not only for scoliosis but also for spine care in general."

Dr. Sethi cited efforts at Northwestern University that aimed to standardize care for high-risk patients. "Risk stratification strategies have led to reductions in various complications that tend to plague spine surgery teams. As physicians, we rarely spend dedicated preoperative time in evaluating these patients as a team. We need to figure out their psychological and social needs along with all their medical concerns."

Key strategies include the use of DEXA (dual-energy X-ray absorptiometry) scans and the possible use of therapeutic drugs such as teriparatide (Forteo), along with endocrine consultations. Under the SST approach, every adult patient who is considered for scoliosis surgery also receives neuropsychological testing and is classified in a green-yellow-orange-red scheme. "Oranges and reds do not go to surgery without major psychiatric optimization!" he said. Patients are given a formal 2.5-hour class on the rehabilitation associated with complex spine surgery.

A presentation of the case is then made in a multidisciplinary conference, with every member of the conference getting an equal vote as to the suitability of the patient for surgery (Fig. 1). "We are removing perverse economic incentives and making sure that we give equal votes to nonsurgeons," Dr. Sethi said.

The concept of team transparency is reinforced with an electronic medical record entry for every patient. The procedure "ensures that patients have been reviewed, identifies who was present, and specifies what the concerns were. Surgery cannot be booked until this is completed."

According to Dr. Sethi, this approach has resulted in "reducing the utilization of adult scoliosis surgery and being much more selective about who receives surgery."

The aggregation advantage
In one study by Dr. Sethi's team, recently published in Spine, 100 patients were offered spinal fusions in outside hospitals in multiple states; Virginia Mason surgeons were given a vote, but were not the primary vote on whether to operate. Other professionals such as physiatrists, anesthesia pain physicians, nurses, and psychologists were also given votes. "We found that approximately 60 percent of patients were recommended for nonsurgical management," Dr. Sethi said. "We also know from other areas that boosting medical judgments results when you use teams of people aggregating independent judgments of doctors."

To increase the value of health care in the future, it is important to predict complications. "It will be system-specific," Dr. Sethi said. "For every system, there needs to be a score that takes into consideration the age of a patient and the main comorbidities that are driving complications within that system."

The SST approach assigns such a grade and uses a preoperative evaluation protocol for risk stratification (Fig. 2). "We are able to demonstrate preoperatively what the patient's risk of complications is and then to risk stratify from that," he said, "to determine whether surgical or medical management will result in optimal outcomes."

At this point, the decision to include the patient in a care bundle can also be made. "We are doing bundles now for simple spine cases," said Dr. Sethi. "We are looking into whether bundles will continue to work in the future. As you know, there are 7-day, 30-day, and 90-day accountability windows under bundles, during which no additional payments will be made for avoidable readmissions related to complications occurring during those periods.

"The best part of this work is that we are going forward with more of a population health-based approach in an area in which spinal surgery is in the national spotlight," Dr. Sethi continued. "We need mechanisms to increase safety and reduce variability."

He cited another study recently published in the Journal of Neurosurgery Spine of 42,000 patients in the Pacific Northwest in which cohorts were reviewed in a defined period of time, with 100 percent follow-up. Dr. Sethi and his team looked at all of the avoidable complications that Centers for Medicare & Medicaid Services currently focus on. The results demonstrated that use of a risk algorithm improved 30-day complication rates, but not 1-year rates. "More work needs to be done to reduce the complications we see after 30 days," Dr. Sethi said.

"I believe that standardization enhances patient safety," Dr. Sethi concluded. "As spine providers, we have to do a better job of achieving this standardization. The SST approach provides an algorithm to reduce complications by employing the methods of a car manufacturer. We have to choose patients better and say 'no' much more than we usually do, and we have to empower all the people on our team to make these decisions. I believe that the centers that are doing this better are getting rewarded. I'd love for physicians to lead the efforts rather than third-party administrators or outside parties. Let's improve the sustainability of our surgeries for the sake of our patients."

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org