The Institute for Healthcare Improvement–NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

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  • 1 Departments of Neurological Surgery and
  • 2 Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;
  • 3 Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado;
  • 4 Carolina Neurosurgery & Spine Associates, Neuroscience and Musculoskeletal Institutes, Atrium Health Charlotte, North Carolina;
  • 5 Atlantic NeuroSurgical Specialists, Morristown, New Jersey;
  • 6 Goodman Campbell Brain and Spine, University of Indiana, Indianapolis, Indiana;
  • 7 Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee;
  • 8 Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
  • 9 Norton Leatherman Spine Center, Norton Healthcare, Louisville, Kentucky;
  • 10 Department of Neurosurgery, University of California, San Francisco, California; and
  • 11 Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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OBJECTIVE

National databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.

METHODS

The NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.

RESULTS

The novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).

CONCLUSIONS

The NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

ABBREVIATIONS ASA = American Society of Anesthesiologists; EMR = electronic medical record; IHI = Institute for Healthcare Improvement; LOS = length of stay; NPA = NeuroPoint Alliance; ODI = Oswestry Disability Index; QI = quality improvement; QOD = Quality Outcomes Database; SSLC = Spine Surgery Learning Community.

Supplementary Materials

    • Appendix 1 (PDF 637 KB)

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Contributor Notes

Correspondence Anthony L. Asher: Carolina Neurosurgery & Spine Associates, Charlotte, NC. a.asher@cnsa.com.

INCLUDE WHEN CITING Published online August 21, 2020; DOI: 10.3171/2020.5.SPINE20457.

Disclosures This study was supported through a grant from the Neurosurgery Research & Education Foundation (NREF). Dr. Devin: consultant for Stryker Spine and direct stock ownership in Balanced Back. Dr. Knightly: personal relationship with NPA. Dr. Potts: consultant for and royalties from Medtronic. Dr. Foley: consultant for Medtronic; direct stock ownership in Discgenics, DuraStat, LaunchPad Medical, Medtronic, NuVasive, Practical Navigation/Fusion Robotics, True Digital Surgery, Tissue Differentiation Intelligence, and Triad Life Sciences; patent holder with Medtronic and NuVasive; royalties from Medtronic; and board of directors of Discgenics, DuraStat, LaunchPad Medical, Practical Navigation/Fusion Robotics, Tissue Differentiation Intelligence, and Triad Life Sciences. Dr. Bisson: consultant for MiRus and Stryker. Dr. Glassman: employee of Norton Healthcare; consultant for Medtronic and K2M/Stryker; royalties from Medtronic; patent holder with Medtronic; clinical or research support from the study described from NuVasive, Integra, Intellirod, Norton Healthcare, Pfizer, and International Spine Study Group (ISSG); editor at Springer; and nonfinancial relationship with SRS (past president) and American Spine Registry (chair). Dr. Mummaneni: consultant for DePuy Synthes, Globus, and Stryker; direct stock ownership in Spinicity/ISD; royalties from DePuy Synthes, Springer Publishing, and Thieme Publishing; clinical or research support for this study from NREF; and support of non–study-related clinical or research effort from ISSG and AO Spine.

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