Sep 5, 2017


Interviewer: Wouldn't it be nice to know the predictable outcome of a surgery before you have the surgery? You'll learn more about that next on The Scope.

Announcer: Health tips, medical news, research, and more, for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Until recently, neurosurgeons lacked reliable data to be able to predict for patients what the outcome for different types of brain surgery would be. But in recent years, thanks to Registry of Data of Surgical Outcomes, physicians now have predictive modeling that helps them better forecast what results patients can expect from certain surgeries. Dr. William Couldwell is a specialist in neurosurgery at University of Utah Health. Tell us about this database.

Dr. Couldwell: So the whole idea of this is a registry and this was conceived of by a number of us as leaders in organized neurosurgery several years ago, probably up to 10 years ago but it was implemented probably in the last 6 or 7 years. So the idea is that if I operate on your back with, say you had a slip disc in your back and you've got leg pain and back pain, if I operate on you, you feel better. But does the ultimate outcome improve your function?

And so that was a question and we knew that third-party pairs were going to be very interested in that outcome. And we also needed to know what to tell and counsel the patients saying that, "If I don't operate on you, this is the expected outcome. If we do operate on you, this is the expected outcome in this timeline."

Interviewer: And up until this point, you really didn't have that information?

Dr. Couldwell: No, we didn't.

Interviewer: Which, I think, a lot of people as a health-care outsider is a little shocking.

Dr. Couldwell: Right, right. So the idea also, too, was to engage a large number of surgeons nationally and have them record their data in a very detailed fashion so that we knew exactly what the outcomes we're expecting so that we could quote these data to the patients and the third-party payers to justify what we were doing for them, to make sure that we were adding value.

And many of the clinical trials that were performed even currently, are very clumsy, they're expensive, they sometimes give us mixed results. So the idea of the registry was a real-world, ongoing, iterative database to demonstrate the outcome of the patients. And so you could then imagine, you could have 1000-cases with some specific disease such as lumbar disc disease and you could implement a treatment and you could compare with the large number of surgeons putting data in in a very short period of time whether the outcome was improved by changing a technique or a pathway of treatment. And so it was a real-world, ongoing feedback to the specialty.

And so, it's important in two ways because it employs the data from a large number of practicing surgeons across the spectrum of private practice, academic institutions across the nation. So you understand what the surgeons are actually doing. And then also, it is a practical . . . it's a patient-reported outcome so the patients are telling us exactly what their outcomes are.

Interviewer: I think there's a couple of things to unpack here. I think thing number one is patient-reported outcome is even something new. There's a lot of metrics that you've been held accountable to by insurance, payers, but very few of them actually did this to improve the patient's life.

Dr. Couldwell: Correct.

Interviewer: Yeah, so that's a different way of looking at things. And then, as a result, you can take a look at two procedures, right? You can compare them and you can find out which one's better which, the assumption is, maybe the more expensive one's better, right, because expensive is always better. But that's not what you learned.

Dr. Couldwell: Absolutely. And also, it avoids the complicating problem with doing clinical trials in that there's often a lot of crossover between the groups in clinical trials. And this allowed us a real-world feedback as to how the data . . . how we were doing with the patients and how the patients perceive their outcomes were. And so, we have back-to-work data, we have disability data, and this is all patient-reported.

Interviewer: And there were some instances where maybe a procedure required more hospitalization, the upfront costs were more, and without having done this comprehensive analysis, you never would have realized that on the backend, though, it actually saves money and that provides better outcome.

Dr. Couldwell: Absolutely. The other derivative benefit is that this has been now the largest ongoing database of spine and patient-reported outcomes in the world. And it's really, the organization nationally of getting all the neurosurgeons to buy into it.

Interviewer: Do other organizations in medicine, are they starting to do this as well now?

Dr. Couldwell: Yes. And I think the leaders in this have been the thoracic surgeons. They've done this for years and I think having neurosurgery applied to treatment of the spine disease is very important, though, because that's a huge cost to the medical system and the report and the outcomes were questionable and they were being questioned in the medical literature. So this gives us a good firm basis for what we're doing.

Interviewer: For somebody that's in a different line of medicine that might want to incorporate this into what they do, what your advice to them? Where do you even start with something like this?

Dr. Couldwell: So we had . . . it was actually fortuitous because we had a number of like-minded individuals in the leadership of our national organization at the time and so we're all very motivated to do this. We understood that the treatment of spine disease was going to be on the radar screen both from federal payers and also third-party payers as to the value of what we're delivering. And so we knew that this was important to do.

What I would recommend is that you need to have a large enough group of people that can coalesce and make this happen because this is a big undertaking. It's a big undertaking organizationally nationally. And secondly, at the individual institution, it requires an investment. We have a full-time FDE that actually records the data and gets the patient-reported outcomes and puts it in the database.

Interviewer: So it's not an easy thing to do. You need a lot of people involved. And I would imagine they could follow your model or thoracic surgeon's model.

Dr. Couldwell: Absolutely. It's an expensive undertaking but we felt it was well-worth it in the long run because we come in, look at the data in a grander fashion. We can see exactly to the group and to the surgeon how the individual surgeons are performing with their outcomes compared to our national benchmarks. Very valuable tool.

Interviewer: Yeah. And then you could also get a very good idea of how a patient's going to do depending on what type of patient they are.

Dr. Couldwell: Absolutely. Absolutely. So we've got these predictive models now and Dr. Bisson can inform you more of this. We have specific predictive modeling for different types of spine in this age or this weight and body mass, probably and mark them.

Interviewer: Yeah. And that allows us to get to a place also in healthcare that we have not been where you could say, "This procedure is going to cost you this much," as opposed to not knowing.

Dr. Couldwell: Exactly. And what their outcome's going to be and we can make a decision of whether it's worth it in that specific demographic group.

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