Improving quality in lumbar fusion surgery through correlation of surgical EBM indications with PROMs

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The aim of this project was to improve overall lumbar spine patients’ care through selection of the most appropriate surgical lumbar fusion candidates by an evidence-based medicine (EBM) review and reanalysis of indications and defining outcomes based on patient reported outcomes measures (PROM). All lumbar fusion cases from March 2018 to August 2019 from a large academic medical center were prospectively evaluated and categorized based on North American Spine Society (NASS) payer coverage policy as concordant or discordant based on fusion indications. Baseline Oswestry Disability Indices (ODI) were collected along with clinical variables. The ODIs were reviewed 6-months postoperatively. Correlation analysis identified variables predictive of improved 6-month ODI and multiple logistic regression identified multivariable-adjusted Odds Ratio of EBM concordance. 309 total lumbar fusion patients were entered into the project and 325 were analyzed with 6 months follow up median preoperative ODI was 24.4 (IQR=19-31) with a median 6-month significant improvement of 7.0 points (IQR=4-13) (p<0.0001). EBM concordance (p=0.0338), lower preoperative ODI (p<0.001), lower ASA (p=0.0056), and primary surgeries (p=0.0004) were significantly associated with improved functional outcome. Age, BMI, smoking status, number levels fused, approach and surgeon were not significant predictors of ODI improvement in multivariate analysis. However, EBM concordance conferred a 3.04 (95% CI=1.10–8.40) times greater odds of achieving minimal clinically important difference in ODI at 6 months (p=0.0322), adjusting for other factors. EBM concordant cases had a greater than three times improved outcome compared to those not meeting EBM fusion indication criteria.



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