1. 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-AR A1
Copyright  2000, Trustees of Dartmouth College

2. 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

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

4. 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

5. 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

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

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

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

9. 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

10. 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

11. 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

12. 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

13. Outcomes
Copyright 2000, Trustees of Dartmouth College

14. 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