The next speaker is Dr. Zuckerman, and the talk is the Institute for Healthcare Improvement, NeuroPoint Alliance, Cooperative Quality Improvement Project, Use of National Registries to Design Continuous Quality Improvement Protocols. Thank you. But just to comment on the baseball study, at Vanderbilt we have a sports concussion center. We see a lot of these athletes, and the one thing, they're all tall, skinny pitchers with the PARS defects, and they really respond to core work, so an intense core regimen rather than a surgery. But it seems to help them the most get back to playing, that we've seen at least. But anyway, thank you very much for the opportunity to present some of this work. Thank you to the scientific committee and our mentors, Dr. Clint Devitt and Dr. Tony Asher, who were influential in this work, and along with several other co-authors. No relevant disclosures. So we know spine surgery makes up about two-thirds of neurosurgery, extremely expensive, and these big registry studies, we know on average, patients do great. We see a host of significant P-values across several outcomes, but there's still about 15 to 20 percent that don't improve, or they require revision surgery. And spine care is the exact high-cost and high-variability discipline, surgeries that we need to study. And though PROs and registries have really improved care, implementation of these QI initiatives is an altogether different entity. This is an editorial published in JAMA several years ago, and the author, Berwick, reviewed two big studies looking, basically comparing a bunch of hospitals engaged in the ACS and NISQIP prospective data registries compared to those not engaged, and found that there was no difference across a host of different morbidities and outcomes. And even though the results were somewhat disappointing, he summarized that it appears the skills necessary to improve care does not really pervade U.S. hospitals. But NISQIP hospitals shouldn't really decrease their investment analysis, they just need to go a step further. Look at information, how to energetically engage this information in the process of learning, skill building, and change. And the last line, I think, is the most profound. Measurement alone is not enough for improvement. So we realized two distinct processes. The first of data collection and analysis, the second one of applied quality improvement, and if we can combine these into a single registry, that was really the impetus for our investigation. So our objective, using the NeuroPoint Alliance and the Institute of Healthcare Improvement Program, to embed insights from registry data with quality improvement efforts in sort of a three-tiered approach, a research phase, an intervention phase, and then a measurement phase. Our pilot population, this is really a pilot analysis and early results, looking at patients undergoing elective lumbar fusion, one to three level. Using the QOD registry, we outlined seven centers looking at these specific spine surgeries all across the country. And the two main outcomes are two of the most common and most impactful from a cost and patient perspective, readmission and length of stay. And going through each phase, the research phase first consisted of in-depth literature reviews, expert interviews, and multivariable regressions trying to identify the key drivers of care. Then the intervention phase was using that information to design novel QI programs to be implemented into the registry, and then measuring. How did the QI tool do? Graphically, just summarizing just that, first it is to define the opportunity, then go to the registry to identify those most powerful, impactful, independent drivers of care, define the quality improvement project, then feed back on the registry to see how much the QI project and the QI tool actually improves care, and then continue that cycle. So getting to the results, the research phase was about a year and a half ago, which consisted of literature reviews and interviews and those multivariable Cox and logistic regressions. And we look at the length of stay numbers, one level fusion had an average length of stay of three, but a wide range of one to 14 days. Two level fusion was slightly longer, ranging from one to 18 days, so we really see a lot of variability there. And 70 percent of patients were discharged in three or more days. Looking at readmission, if we organize it chronologically, week one readmissions were for pain and early wound issues. Week two were medical complications, UTI, pneumonia, et cetera. Week three to four were long-term surgical site infections or late wound issues. And so moving from the research phase to the intervention phase, what can we do with this information? Well, by outlining these barriers to discharge, we put together a length of stay rounding checklist, which just identifies nine different care parameters, basically everything a patient needs to do to leave the hospital itemized in an organized checklist. And this checklist was used at the bedside every day by the entire care team, from the nurse, the physical therapist, the social worker, and the surgeon as well. And the reasons for staying were recorded. Among 36 patients in the early data, mobility status seemed to be the primary driver of staying in the hospital, followed by indwelling devices and pain control. Factors on the first two days of admission were pain, mobility, bowel, bladder. And post-op day three or more were more medical issues and discharge planning process. So looking to future work, how can we use this information for the future? I think it's important that this information should be implemented all across the continuum of healthcare, from comorbidity management, discharge planning, patient activations, these continuous cycles of plan, do, study, act, where you continue to optimize care until really the patients are getting the best care possible. And then you can start to organize the flow of care from when a patient sees you preoperatively to OR, PACU, inpatient stay, post-acute care. So again, you're continually improving using the registry data that you have to outline the most important factors and then measure the change that you do. So concluding, we really tried to combine two separate entities, this idea of data collection and quality improvement into a single registry format to create a living QI instrument with the hope of looking to the future, being able to dispense these QI toolkits to other programs throughout the country and linking these two complementary competencies in a way through a single unit of a registry. So thank you very much for your time and I appreciate it. Thank you. Thank you very much.

national registries

continuous quality improvement

spine surgery

patient-reported outcomes

elective lumbar fusion surgeries