Assessing variability in surgical decision making among attending neurosurgeons at an academic center

View More View Less
  • 1 Department of Neurosurgery and
  • 2 McKenna EpiLog Fellowship in Population Health, Department of Neurosurgery, University of Pennsylvania, Philadelphia; and
  • 3 West Chester University, Department of Mathematics and West Chester Statistical Institute, West Chester, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Although it is known that intersurgeon variability in offering elective surgery can have major consequences for patient morbidity and healthcare spending, data addressing variability within neurosurgery are scarce. The authors performed a prospective peer review study of randomly selected neurosurgery cases in order to assess the extent of consensus regarding the decision to offer elective surgery among attending neurosurgeons across one large academic institution.

METHODS

All consecutive patients who had undergone standard inpatient surgical interventions of 1 of 4 types (craniotomy for tumor [CFT], nonacute redo CFT, first-time spine surgery with/without instrumentation, and nonacute redo spine surgery with/without instrumentation) during the period 2015–2017 were retrospectively enrolled (n = 9156 patient surgeries, n = 80 randomly selected individual cases, n = 20 index cases of each type randomly selected for review). The selected cases were scored by attending neurosurgeons using a need for surgery (NFS) score based on clinical data (patient demographics, preoperative notes, radiology reports, and operative notes; n = 616 independent case reviews). Attending neurosurgeon reviewers were blinded as to performing provider and surgical outcome. Aggregate NFS scores across various categories were measured. The authors employed a repeated-measures mixed ANOVA model with autoregressive variance structure to compute omnibus statistical tests across the various surgery types. Interrater reliability (IRR) was measured using Cohen’s kappa based on binary NFS scores.

RESULTS

Overall, the authors found that most of the neurosurgical procedures studied were rated as “indicated” by blinded attending neurosurgeons (mean NFS = 88.3, all p values < 0.001) with greater agreement among neurosurgeon raters than expected by chance (IRR = 81.78%, p = 0.016). Redo surgery had lower NFS scores and IRR scores than first-time surgery, both for craniotomy and spine surgery (ANOVA, all p values < 0.01). Spine surgeries with fusion had lower NFS scores than spine surgeries without fusion procedures (p < 0.01).

CONCLUSIONS

There was general agreement among neurosurgeons in terms of indication for surgery; however, revision surgery of all types and spine surgery with fusion procedures had the lowest amount of decision consensus. These results should guide efforts aimed at reducing unnecessary variability in surgical practice with the goal of effective allocation of healthcare resources to advance the value paradigm in neurosurgery.

ABBREVIATIONS CFT = craniotomy for tumor; GBM = glioblastoma; IRR = interrater reliability; NFS = need for surgery.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Neil R. Malhotra: Hospital of the University of Pennsylvania, Philadelphia, PA. nrm@uphs.upenn.edu.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.2.JNS182658.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Birkmeyer JD, Sharp SM, Finlayson SR, Fisher ES, Wennberg JE: Variation profiles of common surgical procedures. Surgery 124:917923, 1998

    • Search Google Scholar
    • Export Citation
  • 2

    Chassin MR, Brook RH, Park RE, Keesey J, Fink A, Kosecoff J, : Variations in the use of medical and surgical services by the Medicare population. N Engl J Med 314:285290, 1986

    • Search Google Scholar
    • Export Citation
  • 3

    Glaser JA, Jaworski BA, Cuddy BG, Albert TJ, Hollowell JP, McLain RF, : Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study. Spine (Phila Pa 1976) 23:975983, 1998

    • Search Google Scholar
    • Export Citation
  • 4

    Glover JA: The incidence of tonsillectomy in school children: (Section of Epidemiology and State Medicine). Proc R Soc Med 31:12191236, 1938

    • Search Google Scholar
    • Export Citation
  • 5

    Irwin ZN, Hilibrand A, Gustavel M, McLain R, Shaffer W, Myers M, : Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine (Phila Pa 1976) 30:22082213, 2005

    • Search Google Scholar
    • Export Citation
  • 6

    Mroz TE, Lubelski D, Williams SK, O’Rourke C, Obuchowski NA, Wang JC, : Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. Spine J 14:23342343, 2014

    • Search Google Scholar
    • Export Citation
  • 7

    Oshima Lee E, Emanuel EJ: Shared decision making to improve care and reduce costs. N Engl J Med 368:68, 2013

  • 8

    Pannell WC, Savin DD, Scott TP, Wang JC, Daubs MD: Trends in the surgical treatment of lumbar spine disease in the United States. Spine J 15:17191727, 2015

    • Search Google Scholar
    • Export Citation
  • 9

    Patil PG, Turner DA, Pietrobon R: National trends in surgical procedures for degenerative cervical spine disease: 1990-2000. Neurosurgery 57:753758, 2005

    • Search Google Scholar
    • Export Citation
  • 10

    Wang MC, Kreuter W, Wolfla CE, Maiman DJ, Deyo RA: Trends and variations in cervical spine surgery in the United States: Medicare beneficiaries, 1992 to 2005. Spine (Phila Pa 1976) 34:955963, 2009

    • Search Google Scholar
    • Export Citation
  • 11

    Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES: United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 31:27072714, 2006

    • Search Google Scholar
    • Export Citation
  • 12

    Wennberg JE: Time to tackle unwarranted variations in practice. BMJ 342:d1513, 2011

  • 13

    Wennberg JE, Barnes BA, Zubkoff M: Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 16:811824, 1982

Metrics

All Time Past Year Past 30 Days
Abstract Views 82 82 66
Full Text Views 39 39 36
PDF Downloads 40 40 32
EPUB Downloads 0 0 0