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It is time to refocus on outcomes data collection
Although the 1990s iteration of “managed care” saw major efforts focused on patient-related outcomes data, the data collection process was cumbersome and its utility proved to be limited. As it turns out, while there are many validated patient-related outcomes measures, which are disease specific, they often do not have the sensitivity to distinguish nuances of surgical techniques or decisions. Moreover, the general health status measures that allow comparison between disease states and calculation of quality adjusted life years are also often not specific enough to detect improvements attributable to more expensive treatments or devices.
Superimposed in this milieu of imperfect data and collection is an increasing reliance on patient satisfaction or customer service as reported on blogs, grading websites and now directly collected by CMS. The re-energization of health care reform 2 decades later begs that the old questions about outcomes data be re-asked. Should I collect it? What data should be collected? How much do I need? How will I use the data?
Scott D. Boden
Decision to collect
The decision to collect outcomes data depends on several factors. If the government and payers will have the sophistication to accept outcomes data, then it could be useful to demonstrate differences in outcomes between institutions or even within institutions at a provider or treatment protocol level. This could be used to justify reimbursement for more expensive technology. Alternatively, if one spine surgeon is using lumbar pedicle screw instrumentation routinely in single-level fusions for degenerative spondylolisthesis and another surgeon performs in situ fusions with the same outcomes, then why should that hospital pay thousands of dollars for spinal implants in that subgroup of patients? If surgeons, systems and payers are willing to ask these tough questions and change behavior, then by all means patient-related outcomes data should be collected and can help trim some of the necessary fat out of the health care budget. However, if the primary determinant of decision making will be based on customer service assessments, because patient satisfaction is far easier to measure and report, then broad-based physician-level outcomes data collection efforts may be less valuable.
Once an individual, group or system has made the decision to collect outcomes data, the next question centers around what data to collect. In general, either Short Form 36 or EuroQuol-5D will allow calculation of quality adjusted life years, which can be useful if resource allocation between procedures, diseases or different specialties is important. In addition, a validated disease-specific measure, such as Oswestry Disability Index or Neck Disability Index, is also useful to capture some of the spine-specific nuances of outcomes. Patients have a limited tolerance for answering these questions, such that the more data that is desired the greater the likelihood of patient fatigue and poor compliance.
How much is enough
Another issue to be reckoned with is the determination of how much data are enough. For a publishable research study, standard conventions would strive to have 80% patient follow-up. In contrast, Gallop polls make their conclusions from samples of 5% or less of population groups. If the data are being collected to compare the effectiveness of two different treatment approaches for the same disease (as in the example above with pedicle screw fixation), then a random sample of 25% to 50% of the patient population may be sufficient provided the sampling is continued long enough to get sufficient size samples from each treatment.
The last question to consider is how the data will be used. The hope of some in the 1990s for data collection to show that their personal outcomes were better than others and thereby garner higher reimbursement was not realized. Other data collected in implant registries can be useful to identify implants that are failing early or associated with unanticipated adverse events. It is likely that movement away from a fee-for-service system will require changes in rationale and use of outcomes data. In a value-based health care economy, decreasing the cost per unit care delivered while maintaining or increasing quality and satisfaction will be essential for success. In this paradigm, patient outcomes data collection could provide a “true north” when attempting to minimize unnecessary variation and expense between surgeons and/or institutions.
Health care environmental changes should prompt a refocus on patient outcomes data collection. As we attempt to remove waste from the system it will be important to ensure we are not compromising quality of care or patient satisfaction – the latter of which is easier to measure and more easily understood and communicated with the public. Hopefully technology improvements since the 1990s will enable more cost-effective collection of patient outcomes data. However, the challenge will always be to ensure its conclusions are not stretched beyond the reliability and sensitivity of the instruments nor the statistical power of the data.
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Disclosure: Boden has no relevant financial disclosures.