Neal Shonnard, MD Spine SCOAP Medical Director Bree Collaborative Meeting October 1, 2012

1. Washington State’s Spine Community Working to Improve Surgical Quality:A Proposal to the Bree Collaborative Neal Shonnard, MDSpine SCOAP Medical DirectorBree Collaborative MeetingOctober 1, 2012

2. Presentation Outline • Recap of Bree Collaborative vote at August 1stBree Collaborative meeting • Recap of Spine SCOAP Registry Proposal to Bree Collaborative • Background on Spine SCOAP • Registry components • Benefits of Spine SCOAP to hospitals/communities • Enforcement • Next Steps

3. Spine SCOAP Registry – 8/1 Bree Collaborative meeting RECAP Adopted motion at 8/1/12 Bree Collaborative meeting: • “To support the notion that the community moves in the direction of reporting all spine interventions to a community registry such as Spine SCOAP, and will take into account implementation of this recommendation at the next Bree Collaborative meeting when more information is presented.”

4. Proposal of Spine SCOAP Spine SCOAP requests the Bree Collaborative establish participation in Spine SCOAP as a community standard*. *Starting with hospitals performing spine surgery.

5. What is Spine SCOAP? • Clinician-led quality improvement using clinical data • Performance benchmarking at hospital level • Peer networks • Focus on quality and cost-effectiveness • Spotlighting variation • Impacts behavior through: • Benchmarking • Education • Standard orders • Checklists

6. Who runs Spine SCOAP? Clinician-led Advisory Board of Experts 16 hospitals Foundation for Healthcare Quality Roles of Advisory Board Metrics committee defines standards Target new procedures Address medical/legal issues Funding Hospital pays abstractors and a modest yearly fee Research grants support growth

7. Spine SCOAPClinical Leadership Committee

8. Spine SCOAP’s Agenda • Shared goal: Improve patient access to higher quality, appropriate spine surgery • To accomplish goal, need: • Collaborative of all stakeholders • Real-world data to know what’s being done and to track outcomes that matter • Keys to success • Build on success of the WA State surgical community • Spine community owning variability/inviting collaboration • Focus on quality and safety • Later address variability in indications/appropriateness

10. 4 year Reoperation After Lumbar Decompression, by WA State Hospital Brook Martin, MPH PhD Candidate-work in progress

11. Spine SCOAP Development • Data Sources (abstracted medical record data & surveying for patient reported outcomes) • 4000 cases to date, focusing on fusion • 16 hospitals (80% of eligible spine procedures) • Consecutive Spine Operative Procedures: • Discectomy • Laminectomy • Fusion • Disc replacement • Patient Reported Outcomes • Baseline and follow up regarding Quality of Life and functional outcomes through 5 years

12. Types of Included Data Metrics • Risk adjustment metrics • Indication metrics • Technique metrics • Peri-operative process metrics • Risk adjusted clinical outcome metrics • Functional outcome and pain metrics

13. Data Submission • Frequency: • Real-time: • Data may be entered directly into the Spine SCOAP database • Data is available for querying as soon as it is entered • At a minimum, many hospitals batch data on a quarterly basis • Mechanics: • Database Vendor: ARMUS • Data submission via secure web portal

14. Participation Costs: An Example • Mid-Sized Hospital, 400 procedures/year: • Annual Participation Fee: $5,000 • Case Abstraction • Cost varies based on who is doing the abstracting • If in-house abstraction, cost estimate ranges from $35-50/case • Outsourced abstracting costs range $25-35/case (depending on vendor, EHR, etc.)--example is using mid-range outsourcing cost= $12,000 • Patient Surveying (Baseline through one year): $24,000 • Total Cost (Fee+Abstraction+Surveys): $41,000

15. Transparency • Washington State Spine Forum: Quarterly public access to spectrum of Spine SCOAP data • Planned yearly risk-adjusted, outcome-oriented reports for hospitals and stakeholders

16. Opportunities/Benefits to Hospitals & Community • Reducing variability in quality, cost, and indications for surgery • Addresses perception of inappropriate care • Determine appropriateness by assessing functional changes over time • Opportunity for real world comparative effectiveness research related to value of interventions • Key component of Washington State Spine Forum • Hospital-level data is not discoverable as covered by Washington State CQIP statute

17. Consequences/Risks of Participation • Hospitals absorb costs of FHCQ registration and data abstraction • Reputational risk to not participating in peer-led initiative aimed at improving quality

18. Per Bree Collaborative Legislation: • Bree Collaborative makes recommendations to the WA Health Care Authority (HCA) but does not have authority to enforce implementation of its recommendations • HCA reviews the BreeCollaborative’s recommendations and decides if any or all recommendations will be applied to state purchased programs (e.g,, Medicaid, WA Public Employee health plan, Dept of Corrections)

19. Furthering the Goals of the Bree • Reducing variability in indications and outcomes across centers/surgeons • Quarter by quarter improvements • Works through peer-to-peer networks and “outlier” effect • Real world CER and PCOR studies show what works and what doesn’t, in which patients, and when • Informs WA State HTA decisions, payment and regulatory policy

20. Next Steps • If approved, Spine SCOAP will submit formal proposal (summation of slides)

21. Proposal of Spine SCOAP Spine SCOAP requests the Bree Collaborative establish participation in Spine SCOAP as a community standard*. *Starting with hospitals performing spine surgery.