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This is a pre-copyedited, author-produced version of an article accepted for publication in Neurosurgery following peer review. The version of record:

James Harrop, MD, MSHQS, Alexandra Emes, BS, Ameet Chitale, MD, Chengyuan Wu, MD, Fadi Al Saiegh, MD, Geoffrey Stricsek, MD, Glenn A Gonzalez, MD, Jack Jallo, MD, PhD, Josh Heller, MD, MBA, Kevin Hines, MD, Lucas Philipp, MD, Sara Thalheimer, BA, Srinivas K Prasad, MD, MS, Thiago S Montenegro, MD, Umma Fatema, BS, Ashwini Sharan, MD, MSHQS, Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project, Neurosurgery, Volume 89, Issue 1, July 2021, Pages 77–84

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BACKGROUND: United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines.

OBJECTIVE: To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications.

METHODS: All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance.

RESULTS: A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not.In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors.

CONCLUSION: This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.

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