The National Neurosurgery Quality and Outcomes Database (N2QOD) is the first nationwide effort to collect data on safety, quality and cost-effectiveness in neurosurgery. The database was launched by the NeuroPoint Alliance (NPA), which was established by the American Association of Neurological Surgeons (AANS) in 2008. NPA is also supported by the Congress of Neurological Surgeons, American Board of Neurological Surgery, Society of Neurological Surgeons and AANS/CNS Joint Section on Spine & Peripheral Nerves.
N2QOD was formally launched in February 2012 and currently has 31 sites under contract. About 500 patients per month are enrolled from 46 hospitals in 24 states. Here, Vice President of the NPA Board of Directors and Director of N2QOD Anthony Asher, MD, FAANS, FACS; and Vice Director of N2QOD Matthew McGirt, MD, discuss the database and how to leverage spine surgery data collection for success in the future.
Q: There are several modes of data collection available today. How is N2QOD different from the current methods of data collection in other databases or registries across the country?
Dr. Anthony Asher: The N2QOD is the most comprehensive data instrument yet created for widespread use in the evaluation of spine care outcomes, cost-effectiveness and safety. The N2QOD is designed to allow any surgeon, practice group or hospital to contribute to and access quality and outcomes data to a national registry. Surgeons, and surgeon groups will be able to use the N2QOD to define national quality and performance measures in spine care, develop risk-adjusted national benchmarks for care, and determine the variables most likely to drive clinical outcomes. The latter feature will be particularly important in promoting informed, shared decision-making with patients. The practice level quality and efficiency data generated by N2QOD will facilitate local quality improvement efforts, support claims to public and private payors, help protect patient access to spine care and support other practice data collection requirements such as MOC. Additionally, the registry infrastructure is designed to promote essential scientific discovery in spine care. Dr. McGirt can comment on the unique patient-centered aspects of the registry and other essential features.
Dr. Matthew McGirt: Most quality reporting platforms are confined to the measurement of surgical safety. N2QOD measures both the safety and the effectiveness of care. Value of healthcare interventions cannot be assessed without measurement of effectiveness of care. Among the many features that are unique to N2QOD is its focus on quality of life measures. N2QOD as a registry platform places the patient first, and defines quality of surgical care primarily by patient-
reported measures of pain, disability, quality of life, satisfaction and return to work. Most patients seek spine care due to limitation in their quality of life and pain-related disability. Hence, it is vital to measure effectiveness of care focusing on these patient-centered domains of health. Secondly, N2QOD's robust risk adjustment lies at the heart of its accuracy as a quality-measurement platform. Many factors contribute to variation in outcome, and variation in the safety and effectiveness of care only contributes to part of the story. Without accurately measuring the disease-specific risk factors that influence outcome, a registry cannot adjust for the variation between surgeons' and hospitals' patient populations in order to draw meaningful conclusions on quality of care.
Current quality-measurement platforms utilize broad, non-disease-specific variables that have no bearing on spine outcomes in an attempt to risk adjust. Use of those risk-adjustment models that are not validated in spine disease cannot decipher the signal from the noise. N2QOD uses 30 spine-specific clinical variables to adjust for all of the confounding factors that effect outcome, so N2QOD can accurately identify the treatment options of highest safety, effectiveness and value. Surgeons and hospitals that take on higher-risk patients and disease will not be unfairly profiled as they are in emerging public profiling platforms.
Q: How are most hospitals collecting spine surgery data now and what will they need to change for future regulatory requirements?
MM: Most hospitals rely on billing claims data in an attempt to understand simple measures of surgical complications, hospital readmissions and re-operations. However, administrative non-clinical data has been shown to have a high error rate and offers very little information on the details of patients or their disease. The advantage of this approach has historically been that it was the only feasible way to obtain health operations data in large volumes. Because there is a rush by all stakeholders to use analytics to make better decisions, administrative proxies of clinical measures are overused in today’s environment. Societies such as the AANS want to empower everyone vested in delivering spine care to utilize accurate data to inform their decision making in a meaningful way. That's why we have been developing N2QOD.
Q: All of healthcare seems to be shifting as data collection plays a more prominent role in care delivery. What factors are changing the way spine care is practiced and delivered?
AA: Spine care is perhaps being most influenced by the rapid development of technologies, allowing for a greater spectrum of spine disorders to be successfully treated; safer, less invasive approaches to surgical pathologies; and enhanced healing after spinal procedures. As a consequence of this proliferation of technologies in conjunction with an aging population, the number and type of spine-related therapies has exploded. With the rapid expansion has come a dramatic increase in the overall cost of spine-related healthcare.
These costs have become a focus of attention and analysis for a variety of powerful healthcare stakeholders, including large purchasers of care, patient groups and private payors. This dynamic is fueling the demand for objective data that supports the value and safety of spine care.
Q: With all the changes in healthcare coming forward, how will providers use this data in the future?
MM: N2QOD is especially valuable to spine providers and surgeons. N2QOD serves as a learning health system, empowering providers in their practice-based learning advancement. As spine providers and surgeons evolve in their treatment approaches, quarterly N2QOD reports will provide analytical feedback on the patient-centered effect of their treatment decisions. This will enable identification of best practices, practice-level comparative effectiveness and continual quality improvement. Many decisions on the utilization of techniques or technologies are made by the surgeon based on anecdotal experience. N2QOD analytics will allow surgeons to learn whether their decisions improve outcomes or not. N2QOD empowers evidence-based practice.
AA: Dr. McGirt makes excellent points about the evolving role of practice data analysis in individual surgical practice. With respect to communities of surgeons, I believe successful spine practitioners in five to 10 years will be part of dynamic, collaborative networks in which multiple providers will routinely share data from their individual clinical experience to advance our common knowledge, and cooperatively improve both the safety and value of care.
Aside from advancing clinical science and facilitating practice-based learning, data collection through registries will ultimately allow spine-care specialists to satisfy a variety of external stakeholder requirements including maintenance of specialty board certification, specialty licensing, PQRS and "meaningful use."
Q: How will this database contribute to improving patient care?
MM: This database also is designed for use with patients to help them make informed decisions. When it comes to spine care, we are hoping to facilitate a patient-centered, shared information decision-making process where the patient is empowered to see the data and play a larger role in their treatment. By measuring surgical outcomes in a wide spectrum of patients and diseases nationwide, N2QOD is able to develop more accurate statistical models that can estimate probabilities of outcome personalized to specific patients’ characteristics. This advancement in patient-decision aids will inform the patient more than ever before, and will hopefully maximize the patient satisfaction and the odds of meeting patient expectations.
AA: I agree with Dr. McGirt's assessment. I would only add that independent of the impact of registries on patient-centered goals such as shared decision making, N2QOD and similar data-collection programs will greatly enhance the safety and value of spine care by allowing us to more objectively identify the patients most likely to benefit from specific procedures, and determine the relative effectiveness of a variety of interventions for specific disease states.
Q: Are there any challenges for data collection?
MM: The biggest challenge registries face is collecting healthcare data across the continuum of care, from the pre-operative diagnostic episode, through the inpatient perioperative episode, to the post-operative outpatient episode. No nationwide registry effort has attempted to collect patient-reported healthcare data spanning this 12-month continuum of care. Thus far, N2QOD has been successful in our aim to do so with high data fidelity.
Q: What are your overall goals for N2QOD?
AA: Our goal is to provide the most stable, reliable and efficient information technology system for surgeons, administrators and other healthcare stakeholders across the country to more objectively assess the value of spine care. We ultimately plan to incorporate structural changes in the registry to produce greater efficiencies and allow for integration with related information systems. In that respect, our ultimate objective is to fundamentally transform the culture of spine care by allowing individuals and groups to seamlessly integrate our platforms and methodologies into daily practice.
MM: We want all spine-care practitioners to be able to come forward with transparent reports of their value in the broader healthcare community. As groups advertise their services and position themselves for strategic partnerships in the marketplace, they will be able to provide essential information such as rates of return to work, quality of life and patient satisfaction that are not available in most present analyses focused on administrative datasets. Participation in the N2QOD will therefore not only promote the development of quality care, but also will place participating groups in unique positions of advantage in the marketplace.
Q: How do you anticipate data collection and N2QOD will impact healthcare delivery in the future?
MM: With N2QOD, we are currently focusing and targeting orthopedic surgeons and neurosurgeon practices. The data can be shared by any stakeholders, but we leave it up to participating providers as to how they can best utilize the data. We feel that N2QOD will allow for a smarter healthcare system as it relates to spine care by providing a real-world assessment of what works best, in which patients, when and how. While our primary focus right now is on improving surgical quality and defining those benchmarks for the spine provider and patient, as healthcare models change, I suspect we will offers analytics to empower hospital system decision making in the future.
AA: I completely agree with Dr. McGirt’s assessment. Taking a broader view of the importance of routine practice data collection, I think it's important to note that information has become the global currency of the 21st century. Simply put, those who control essential data and who use this data to generate new knowledge and facilitate improvement are able to adapt, effect change, and prosper.
Collecting information from daily experience, using that information to generate new knowledge and applying that knowledge to practice improvement, self education, and other uses are activities grounded in a modern informatics society in which technical knowledge permeates all spheres of life and in which modern experts manage and produce information as their primary activity. In this regard, the systematic collection of data inseparable from clinical activities is not simply a response to abstract or irrelevant external requirements, but an opportunity to survive — and indeed thrive — amidst the increasingly competitive demands of the informatics age.
These skills will be essential for all physicians — and particularly those involved in more technical fields such as spine care — to acquire. Adopting the skills necessary to critically analyze practice, determine opportunities for improvement, and generate new knowledge will make individual spine-care physicians and the field of spine care better.
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