Here are six steps to improve patient outcomes from spine surgery and reduce costs associated with treatment, complications and postoperative readmissions.
1. Identify risk factors for readmissions. Isolate cases where the patient was readmitted and pinpoint the most common reasons at your hospital to reduce the risk of readmissions.
"Understand what the current readmission profile looks like at the hospital and look at the hospital records to comprehend cost implications of readmissions," says Alpesh A. Patel, MD FACS, spine surgeon and Associate Professor in the Department of Orthopaedic Surgery at Northwestern University School of Medicine in Chicago. "Really hone in on the most important risk factors and partner with others to eliminate them. For example, if there are several readmissions because of infections, you'll need to partner with the hospital on a stronger infection control policy."
Some of the most common risk factors for readmissions across the country include:
• Medical comorbidities
• Age of the patient
• Type of procedure performed (open vs. minimally invasive)
• Number of levels fused
• Pain control
• Infection
Don't just rely on the ICD-9 coding data or hospital billing records; really examine patient records for readmissions to conduct a root cause analysis. After you've identified the risk factors, develop protocol to reduce the risk.
2. Stick to appropriate protocols. Surgical complications also drive up costs, and working to eliminate complications plays an important role in controlling costs. The cost of a post-operative pulmonary embolism or a wrong level surgery is massive, says Robert S. Bray, Jr., MD, is the founder and CEO of DISC Sports & Spine Center in Marina del Rey, Calif.
An important step to minimizing complications is setting protocols for all surgeons to follow. Post-operative protocols, including proper catheter drainage and use of the bladder to avoid infection, result in huge cost savings for patients and providers.
"Protocol management of patients to avoid complications dramatically reduces the cost of delivering care," he says. "This involves education of the nursing staff and proper selection of surgeons."
3. Pay attention to appropriate patient selection. Proper patient and indication selection is crucial to the success of a surgery and can keep patients from needing revision surgeries or other costly follow-up visits.
"Eighty percent of healthcare dollars spent on spine are spent on failures in spine, including failures that result in long-term drug use or pain management," Dr. Bray says.
Surgeons must maintain the ability to use their best judgment and knowledge to select patients who are proper candidates for surgery. Insurance companies try to get involved in patient selection, but "you can't have them do that," he says. It's the wrong place for oversight.
4. Conduct a time out while the patient is still awake. All operating rooms have a "time out" before beginning surgery to make sure everyone is on the same page about what procedure is being performed, what the surgeon needs for the case and confirm everyone has gone through proper infection control policy. Often, this comes as the last step before surgery, Brian R. Gantwerker, MD, of The Craniospinal Center of Los Angeles, suggests doing the "time out" before the patient receives anesthesia to further decrease the risk of complications.
"One way to do this is that when the patient comes into the room, do the time out while the patient is awake and then induce anesthesia," says Dr. Gantwerker. "That way there are no pauses at inopportune times and the patient participates in the process, which is a great way to avoid errors and enhance safety."
The surgeon should also create a comfortable environment for the surgical staff during these time outs so they can raise questions without fear of being reprimanded for slowing down the surgeon. High quality will supersede high case volume in terms of cost and patient satisfaction, regardless of the surgical technique.
"Doing more cases isn't always the answer," says Dr. Gantwerker. "Doing cases safely and efficiently is key. Doing three or four cases and being able to say there isn't confusion or problems with the wrong level are better than having a high volume with a high risk for problems."
5. Provide patients with discharge instruction sheets. Benjamin R. Cohen, MD, FAANS, FACS, a spine surgeon with Neurological Surgery in Lake Success, N.Y., gives each patient a discharge instruction sheet he acquired during his fellowship that includes general information, activities to avoid and what problems are serious after surgery.
"This information tells them what they can expect as normal and what they should call my office about," says Dr. Cohen. Patients can refer to the instruction sheets at home if they forget verbal instructions from pre-discharge conversations.
6. Make a midlevel practitioner available to answer questions. When patients experience minor complications after surgery, such as issues swallowing or spasms, they might unnecessarily go to the emergency room for help. However, if you connect them with a midlevel provider instead, they could call that person to assess whether an ER visit is necessary.
"It's helpful to have a nurse practitioner or physician's assistant to help when patients have questions," says Dr. Cohen. "When patients get readmitted, assuming it's not an emergency, it's often because they don't know what else to do. If you have an option for them to call your office during the day and reach a nurse, the problem can be solved over the phone."
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