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A Strategy for Risk-Adjusted Ranking of Surgeons and Practices Based on Patient-Reported Outcomes After Elective Lumbar Surgery

Sivaganesan, Ahilan, MD*; Asher, Anthony L., MD; Bydon, Mohamad, MD; Khan, Inamullah, MD*; Kerezoudis, Panagoitis, MD; Foley, Kevin T., MD§; Nian, Hui, PhD; Harrell, Frank E. Jr., PhD; Archer, Kristin R., PhD, DPT||; Devin, Clinton J., MD*

doi: 10.1097/BRS.0000000000002894
Surgery: PDF Only

Study Design. This study retrospectively analyzes prospectively collected data.

Objective. The primary aim of this study is to present a scheme for PRO-based, risk-adjusted rankings of spine surgeons and sites that perform elective lumbar surgery, using the Quality and Outcomes Database (QOD).

Summary of Background. There is currently no means of determining which spine surgeons or centers are positive or negative outliers with respect to patient-reported outcomes (PRO) for elective lumbar surgery. This is a critical gap as we move towards a value-based model of healthcare in which providers assume more accountability for the effectiveness of their treatments.

Methods. Random effects regression models were fit for the following outcomes, with QOD site as a fixed effect but surgeon ID as a random effect: ODI, EQ-5D, back pain and leg pain, and satisfaction. Hierarchical Bayesian models were also fit for each outcome, with QOD site as a random effect and surgeon as a nested random effect.

Results. Our study cohort consists of 8834 patients who underwent surgery by 124 QOD surgeons, for the degenerative lumbar diseases. Non-overlapping Bayesian credible intervals demonstrate that the variance attributed to QOD site was greater than the nested variance attributed to surgeon ID for the included PROs.

Conclusion. This study presents a novel strategy for the risk-adjusted, PRO-based ranking of spine surgeons and practices. This can help identify positive and negative outliers, thereby forming the basis for large-scale quality improvement. Assuming adequate coverage of baseline risk adjustment, the choice of surgeon matters when considering PROs after lumbar surgery, however the choice of site appears to matter more.

Level of Evidence: 3

*Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, TN

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neurological Institute, Carolinas Healthcare System, Charlotte, NC

Department of Neurological Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN

§University of Tennessee Health Science Center in Memphis, TN

Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN

||Department of Orthopedic Surgery and Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, TN.

Address correspondence and reprint requests to Clinton J. Devin, MD, Department of Orthopedics Surgery, Vanderbilt Spine Center, Vanderbilt University School of Medicine, Medical Center East, South Tower, Suite 4200, Nashville; E-mail:

Received 27 June, 2018

Revised 6 August, 2018

Accepted 10 September, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, royalties, patents, stocks, expert testimony.

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