#79 Implementation and Impact of Pre-operative Peer Case Review in a Spine Practice

General Session: Quality of Spine Care

Presented by: R. Guyer


R.D. Guyer (1)
J. Shivers (1)
D.D. Ohnmeiss (2)
J.E. Zigler (1)

(1) Texas Back Institute, Plano, TX, USA
(2) Texas Back Institute Research Foundation, Plano, TX, USA


Introduction: A vital component of quality surgical care is patient selection. Determining the most appropriate surgical option can be challenging in patients with complex problems. One means of addressing the challenge is implementation of a practice-based peer-review process for select surgical cases. The purpose of this study was to provide an overview of such a program implemented in a private practice and analyze its impact on surgeries performed.

Methods: The pre-operative case review process was formally implemented in 2009 and designed to review proposed surgeries in complex cases, not including neurologic emergencies, deformity, or tumor. Factors qualifying a case for review include a proposed fusion of more than 2 levels, significant anesthesia or vascular risk factors, body mass index of more than 40, multiple previous surgeries at the same level, and advanced age. During the review meeting, indications are presented and rationale for the proposed surgery discussed. The surgeon proposing the surgery is invited to attend the meeting and discuss indications. Outcome of the case review generally is one of the following categories: approval for proposed surgery, recommend modifying the surgical plan based on discussion of options and risks, obtain further diagnostic evaluation and possibly reviewing the case again, or do not schedule the patient for surgery. Surgery records were reviewed to monitor compliance with submitting cases for review. Patients were tracked through a surgery log and quality assurance system to determine if a reviewed patient underwent surgery, and if so, compare the procedure performed to what was recommended by the review committee.

Results: A total of 261 proposed surgeries meeting review criteria were evaluated by the committee. Of these, 189 (72.4%) were approved as proposed. The committee disagreed with the proposed surgery in 72 (27.6%) of the reviewed cases. Among these 72 cases, the committee suggested: no surgery in 2 cases (2.8%), change in surgical plan in 47 cases (65.3%; reducing number of levels, eliminating interbody procedure, eliminating posterior instrumentation, posterior rather than anterior cervical fusion, etc.), and further diagnostic evaluation, including pre-surgical psychosocial screening, in the remaining 23 cases (31.9%) with the possibility of re-reviewing the case based on results of additional evaluations. Among the 72 cases where the committee disagreed with the proposed surgery, the review process altered the proposed surgical plan in 72.2%. Two additional cases (2.7%) were reviewed too recently to classify. In all cases where the committee suggested less extensive surgery, and this was performed as recommended, no further surgery was required.

Discussion: The internal practice-based peer-review program was successfully implemented and remains in effect. The process impacted 23.0% of cases qualifying for review. By employing well-defined written criteria for cases that merit review based on patient risk factors and/or complexity of proposed surgery, cases can be identified and reviewed with the goal of increasing safety and quality by taking advantage of the experience of multiple surgeons to derive a treatment plan after non-operative care has failed. This program can serve as a model for other clinics to provide pre-operative assessment of proposed surgery for challenging spine cases and have an impact on the care provided.