Assessing and Improving the Quality of Care For Low Back Pain Career Development Award Agency For Health Care Research and Quality Supported by NIAMS U01-AR45444-01A1 Copyright  2000, Trustees of Dartmouth College

Background Why assess quality of care for low back pain? Variation in rates of surgery Variation in outcomes of care Copyright 2000, Trustees of Dartmouth College

Variation in Surgery Rates: Dartmouth Atlas of Healthcare Back surgery rates vary widely in U.S. 6 fold after adjustment 1.4-8.6 per 1,000 Medicare enrollees Lack of evidence/clinical consensus Copyright 2000, Trustees of Dartmouth College

Ratio of Rates of Lumbar Discectomy to the U.S. Average (1996-97) Rates of lumbar disc herniation surgery varied by a factor of 22, from 0.1 per 1,000 Medicare enrollees to 2.2, after adjusting for differences in population age, sex, and race. 1 .30 to 3 .08 (75) .10 to < (46) .90 (65) .75 (56) .19 (64) Not Populated Copyright 2000, Trustees of Dartmouth College

Ratio of Rates of Lumbar Decompression to the U.S. Average (1996-97) Rates of lumbar spinal stenosis surgery varied by a factor of 7, from 0.6 per 1,000 Medicare enrollees to 4.4, after adjusting for differences in population age, sex, and race. 1 .30 to 2 .71 (68) .10 to < (53) .90 (72) .75 (54) .39 (59) Not Populated Copyright 2000, Trustees of Dartmouth College

Medicare 1997-1999 Back and Neck Surgery (excluding fusion) Major Complications: Related to implant -Stroke Cardiac arrest -Excessive bleeding Infection

Healthgrades.com Data For SPORT Centers Copyright 2000, Trustees of Dartmouth College

Healthgrades.com Data For SPORT Centers Copyright 2000, Trustees of Dartmouth College

Problems With Medicare Data For Assessing Quality Lack of clinical data Risk-adjustment Process of care Coding unreliable for complications Representativeness of population? Surgical complications is a narrow view of the QOC for LBP Copyright 2000, Trustees of Dartmouth College

SPORT QI Specific Aims Characterize clinical practices Assess outcomes Structure of Care Process of Care Assess outcomes Identify high-leverage areas for improvement by linking variability in clinical practices and outcomes among SPORT sites Copyright 2000, Trustees of Dartmouth College

Structure of Care Relatively fixed physical and organizational aspects of the care system and environment Hospital type (academic, public, private, etc..) Spine surgery case volume Organization of spine services (multidisciplinary versus single specialty, location of ancillary services, etc...) QI activities such as clinical pathways Copyright 2000, Trustees of Dartmouth College

Process of Care Specifics of care that patients receive Diagnostic tests Non-surgical care Medications Physical therapy Counseling Surgical care Pre-op medications Intra-op procedures Post-op treatment plan Copyright 2000, Trustees of Dartmouth College

Outcomes Copyright 2000, Trustees of Dartmouth College

Conclusions Where does undesirable variability occur? What are its effects? What are its causes? How can it best be reduced? Copyright 2000, Trustees of Dartmouth College