Frank J. Attenello, Ian A. Buchanan, Timothy Wen, Daniel A. Donoho, Shirley McCartney, Steven Y. Cen, Alexander A. Khalessi, Aaron A. Cohen-Gadol, Joseph S. Cheng, William J. Mack, Clemens M. Schirmer, Karin R. Swartz, J. Adair Prall, Ann R. Stroink, Steven L. Giannotta and Paul Klimo Jr.
Excessive dissatisfaction and stress among physicians can precipitate burnout, which results in diminished productivity, quality of care, and patient satisfaction and treatment adherence. Given the multiplicity of its harms and detriments to workforce retention and in light of the growing physician shortage, burnout has garnered much attention in recent years. Using a national survey, the authors formally evaluated burnout among neurosurgery trainees.
An 86-item questionnaire was disseminated to residents in the American Association of Neurological Surgeons database between June and November 2015. Questions evaluated personal and workplace stressors, mentorship, career satisfaction, and burnout. Burnout was assessed using the previously validated Maslach Burnout Inventory. Factors associated with burnout were determined using univariate and multivariate logistic regression.
The response rate with completed surveys was 21% (346/1643). The majority of residents were male (78%), 26–35 years old (92%), in a stable relationship (70%), and without children (73%). Respondents were equally distributed across all residency years. Eighty-one percent of residents were satisfied with their career choice, although 41% had at some point given serious thought to quitting. The overall burnout rate was 67%. In the multivariate analysis, notable factors associated with burnout included inadequate operating room exposure (OR 7.57, p = 0.011), hostile faculty (OR 4.07, p = 0.008), and social stressors outside of work (OR 4.52, p = 0.008). Meaningful mentorship was protective against burnout in the multivariate regression models (OR 0.338, p = 0.031).
Rates of burnout and career satisfaction are paradoxically high among neurosurgery trainees. While several factors were predictive of burnout, including inadequate operative exposure and social stressors, meaningful mentorship proved to be protective against burnout. The documented negative effects of burnout on patient care and health care economics necessitate further studies for potential solutions to curb its rise.
Asdrubal Falavigna, Nicolas Scheverin, Orlando Righesso, Alisson R. Teles, Maria Carolina Gullo, Joseph S. Cheng and K. Daniel Riew
Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil.
The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation).
The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained.
The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.
Robert G. Whitmore, Jill N. Curran, Zarina S. Ali, Praveen V. Mummaneni, Christopher I. Shaffrey, Robert F. Heary, Michael G. Kaiser, Anthony L. Asher, Neil R. Malhotra, Joseph S. Cheng, John Hurlbert, Justin S. Smith, Subu N. Magge, Michael P. Steinmetz, Daniel K. Resnick and Zoher Ghogawala
The authors have established a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures using prospectively collected outcomes. Collection of these data requires an extensive commitment of resources from each site. The aim of this study was to determine whether outcomes data from shorter-interval follow-up could be used to accurately estimate long-term outcome following lumbar discectomy.
An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level lumbar discectomy for treatment of disc herniation were included. SF-36 and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Quality-adjusted life year (QALY) data were calculated using SF-6D utility scores. Correlations among outcomes at each follow-up time point were tested using the Spearman rank correlation test.
One hundred forty-eight patients were enrolled over 1 year. Their mean age was 46 years (49% female). Eleven patients (7.4%) required a reoperation by 1 year postoperatively. The overall 1-year follow-up rate was 80.4%. Lumbar discectomy was associated with significant improvements in ODI and SF-36 scores (p < 0.0001) and with a gain of 0.246 QALYs over the 1-year study period. The greatest gain occurred between baseline and 3-month follow-up and was significantly greater than improvements obtained between 3 and 6 months or 6 months and 1 year(p < 0.001). Correlations between 3-month, 6-month, and 1-year outcomes were similar, suggesting that 3-month data may be used to accurately estimate 1-year outcomes for patients who do not require a reoperation. Patients who underwent reoperation had worse outcomes scores and nonsignificant correlations at all time points.
This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. Three-month outcome data may be used to accurately estimate outcome at future time points and may lower costs associated with registry data collection. This registry effort provides a practical foundation for the acquisition of outcome data following lumbar discectomy.
Joseph H. McAbee, Brian T. Ragel, Shirley McCartney, G. Morgan Jones, L. Madison Michael II, Michael DeCuypere, Joseph S. Cheng, Frederick A. Boop and Paul Klimo Jr.
The object of this study was to identify and quantify predictors of burnout and career satisfaction among US neurosurgeons.
All US members (3247) of the American Association of Neurological Surgeons (AANS) were invited to participate in a survey between September and December 2012. Responses were evaluated through univariate analysis. Factors independently associated with burnout and career satisfaction were determined using multivariable logistic regression. Subgroup analysis of academic and nonacademic neurosurgeons was performed as well.
The survey response rate was 24% (783 members). The majority of respondents were male, 40–60 years old, in a stable relationship, with children, working in a group or university practice, and trained in a subspecialty. More than 80% of respondents reported being at least somewhat satisfied with their career, and 70% would choose a career in neurosurgery again; however, only 26% of neurosurgeons believed their professional lives would improve in the future, and 52% believed it would worsen. The overall burnout rate was 56.7%. Factors independently associated with both burnout and career satisfaction included achieving a balance between work and life outside the hospital (burnout OR 0.45, satisfaction OR 10.0) and anxiety over future earnings and/or health care reform (burnout OR 1.96, satisfaction OR 0.32). While the burnout rate for nonacademic neurosurgeons (62.9%) was higher than that for academic neurosurgeons (47.7%), academicians who had practiced for over 20 years were less likely to be satisfied with their careers.
The rates of burnout and career satisfaction were both high in this survey study of US neurosurgeons. The negative effects of burnout on the lives of surgeons, patients, and their families require further study and probably necessitate the development of interventional programs at local, regional, and even national levels.
Aaron J. Clark, Roxanna M. Garcia, Malla K. Keefe, Tyler R. Koski, Michael K. Rosner, Justin S. Smith, Joseph S. Cheng, Christopher I. Shaffrey, Paul C. McCormick and Christopher P. Ames
Adult spinal deformity (ASD) surgery is increasing in the spinal neurosurgeon's practice.
A survey of neurosurgeon AANS membership assessed the deformity knowledge base and impact of current training, education, and practice experience to identify opportunities for improved education. Eleven questions developed and agreed upon by experienced spinal deformity surgeons tested ASD knowledge and were subgrouped into 5 categories: 1) radiology/spinopelvic alignment, 2) health-related quality of life, 3) surgical indications, 4) operative technique, and 5) clinical evaluation. Chi-square analysis was used to compare differences based on participant demographic characteristics (years of practice, spinal surgery fellowship training, percentage of practice comprising spinal surgery).
Responses were received from 1456 neurosurgeons. Of these respondents, 57% had practiced less than 10 years, 20% had completed a spine fellowship, and 32% devoted more than 75% of their practice to spine. The overall correct answer percentage was 42%. Radiology/spinal pelvic alignment questions had the lowest percentage of correct answers (38%), while clinical evaluation and surgical indications questions had the highest percentage (44%). More than 10 years in practice, completion of a spine fellowship, and more than 75% spine practice were associated with greater overall percentage correct (p < 0.001). More than 10 years in practice was significantly associated with increased percentage of correct answers in 4 of 5 categories. Spine fellowship and more than 75% spine practice were significantly associated with increased percentage correct in all categories. Interestingly, the highest error was seen in risk for postoperative coronal imbalance, with a very low rate of correct responses (15%) and not significantly improved with fellowship (18%, p = 0.08).
The results of this survey suggest that ASD knowledge could be improved in neurosurgery. Knowledge may be augmented with neurosurgical experience, spinal surgery fellowships, and spinal specialization. Neurosurgical education should particularly focus on radiology/spinal pelvic alignment, especially pelvic obliquity and coronal imbalance and operative techniques for ASD.
Praveen V. Mummaneni, Robert G. Whitmore, Jill N. Curran, John E. Ziewacz, Rishi Wadhwa, Christopher I. Shaffrey, Anthony L. Asher, Robert F. Heary, Joseph S. Cheng, R. John Hurlbert, Andrea F. Douglas, Justin S. Smith, Neil R. Malhotra, Stephen J. Dante, Subu N. Magge, Michael G. Kaiser, Khalid M. Abbed, Daniel K. Resnick and Zoher Ghogawala
There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes.
An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis.
There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained).
This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.