Care pathways have been embraced as a way to standardize treatment for a wide variety of conditions in order to avoid unnecessary variation and encourage compliance with evidence-based guidelines. They have been popular for common surgical procedures such as total joint arthroplasty and have been shown to reduce length of stay (LOS) and decrease costs. Less has been published about their role in spine surgery, likely due to the heterogeneity and complexity of spine procedures as compared to total joint replacement. However, given the greater duration of surgery and physiological insult associated with major spine surgery, the potential benefits of care standardization could be even greater in the complex spine surgery population. In order to assess their results associated with a care pathway for major spine surgery, Dr. Dagal and colleagues from Harborview Medical Center in Seattle compared outcomes before and after implementation of their care pathway for major spine surgery. The pathway included preoperative, intraoperative, and postoperative phases and focused on education, nutrition, minimizing physiological disruption, pain control, and early postoperative mobilization. Their main outcome measures were hospital and ICU LOS. Postoperative complications, 30-day readmission, and cost were secondary outcomes. Eligible patients were undergoing major spine surgery (defined as primary fusion involving at least 4 levels, revision surgery including at least 3 levels, AP fusion, anticipation of greater than 6 hours of surgery or greater than 1L of blood loss, corpectomy, pedicle subtraction osteotomy, or revision anterior fusion), had significant medical comorbidities, were taking buprenorphine, or had a pain pump or stimulator present. The pre-pathway cohort included 183 patients who underwent surgery between 2012-2013, and the post-pathway cohort included 267 patients who underwent surgery between 2015-2016. The authors also included a cohort of 108 patients who underwent surgery from 2015-2016 who were eligible for the pathway but who were not placed on the pathway due to logistical issues as a contemporaneous control group. They found that the pathway patients had significantly lower hospital LOS (6.1 days) compared to the pre-pathway (8.2 days) and contemporaneous control (7.6 days) groups. The average ICU stay was also one day shorter for the pathway group compared to the other two groups. The pathway and contemporaneous control groups were both less likely to be admitted to the ICU compared to the pre-pathway group. Complication and readmission rates were similar for the three cohorts. The total cost of care was about $9000 less for the pathway group compared to the pre-pathway group and about $4,500 less compared to the contemporaneous control group.
The authors should be congratulated for performing the multidisciplinary work necessary to create such a pathway in a bureaucratic academic medical center. Their study demonstrates a significant improvement in length of stay and cost, without an increase in complication or readmission rate. Before-after studies evaluating outcomes in a real practice environment are always limited by potential confounders and secular trends (i.e. practice change over time not related to the intervention), though the authors attempted to mitigate this through the use of a contemporaneous control group. While that group may have been different in unmeasured ways compared to the pathway group, inclusion of that group is probably the best the authors could do in order to control for secular trends. This study does demonstrate the benefit of a care pathway for complex spine surgery, and many institutions have made efforts to adopt spine surgery care pathways. The most difficult aspects of implementing such a pathway are getting a diverse group of providers to agree on the details of the pathway and then actually getting the multidisciplinary (i.e. nurses, physical therapists, social workers, anesthesiologists, orthopaedic spine surgeons, and neurosurgeons) group to follow it. Hopefully this paper can be an inspiration to other institutions to do the hard work necessary to implement such a pathway.
Please read Dr. Dagal's paper on this topic in the July 1 issue. Does this motivate you to work on a care pathway in your institution? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor