Establishing a Reference Procedure Length for Anterior Cervical Fusions: The Role for Standards in Surgical Process Improvement
By Admin | March 18, 2022
Surgical process improvement strategies are increasingly being applied to specific procedures to improve value. A critical step in any process improvement strategy is the identification of performance benchmarks. Procedure length is a performance benchmark for anterior cervical discectomy and fusion (ACDF) procedures; therefore, we sought to establish reference procedure lengths for 1-level, 2-level, and 3-level ACDFs at both teaching and non-teaching institutions and to describe methods for using this information to advance surgical process improvement initiatives. We performed a retrospective analysis of consecutive ACDFs performed at a resident teaching institution (RT) and a non-teaching institution (NT) for all 1-level, 2-level, and 3-level ACDFs. Mean case lengths and patient outcomes were calculated for individual surgeons and institutions. After limiting cases to 1-level, 2-level, and 3-level ACDFs and applying all exclusion criteria, 991 cases at the RT institution and 131 cases at the NT institution (a total of 1122 cases) were available for analysis. The mean (SD) procedure length for 1-level, 2-level, and 3-level ACDFs at the RT versus NT institutions were 121.9 min (36.3 min) and 73.6 min (29.7 min) (p<0.001), 172.7 min (44.8 min) and 112.0 min (43.0 min) (p<0.001), and 218.3 min (54.9 min) and 167.6 min (54.2 min) (p<0.001), respectively. Thirty-day outcomes were the same between institutions, except that the RT institution had a shorter mean hospital length of stay for 2-level ACDFs (1.6 days versus 2.9 days, p=0.001). This study is the first to attempt to establish a standard reference procedure length for 1-level, 2-level, and 3-level ACDFs. These data can guide efforts in surgical process improvement.
As healthcare expenditures in the United States continue to rise at an unsustainable rate, the value of certain surgical procedures is being increasingly scrutinized . Because of the high global prevalence of spine disease and the increasing rate of surgical treatment of the spine, many researchers have begun focusing on evaluating and improving the safety and value of spinal surgery [2-4]. Cervical spine surgeries are among the most commonly performed procedures in the United States, with an increase in the diagnosis and surgical treatment of degenerative cervical disease over the previous decade [5-7]. Continued efforts are therefore warranted to improve outcomes and reduce costs for these procedures.
Surgical case length is one of the strongest predictors of adverse outcomes and increased costs in anterior cervical discectomy and fusion (ACDF) procedures [8,9]. It is difficult to establish operative time as a truly independent predictor of outcomes because of its close relationship to the severity of pathology being addressed. However, a recent study evaluating more than 15,000 single-level ACDFs found that additional operative times of as little as 15 minutes were predictive of worse outcomes . The authors of this study concluded that surgeons should maximize operative efficiency as much as safely possible, as even a 15-minute improvement in case length could lead to better outcomes. Another study has shown that case length is one of the biggest drivers of 90-day costs for elective ACDFs . Efforts to reduce ACDF procedure length might therefore improve value both by reducing costs and improving outcomes.
Many studies evaluating patient outcomes after ACDF procedures report a mean procedure length for their study population, but none report these variables with enough granularity to establish a standard reference procedure length for ACDF [8-16]. For example, many studies combine 1-level, 2-level, and 3-level ACDFs (or two of the three procedure types) in their reported mean or median operative length calculation [9,11-13]. Other studies combine ACDFs and cervical disc arthroplasties in procedure length calculations . Others report on 1-level ACDFs only but do not differentiate between procedures done at teaching institutions with residents and those done at non-teaching institutions . The presence of residents in various neurosurgical procedures has been demonstrated to increase procedure length, though none of these studies have shown worse outcomes as a result [17-22]. In an increasingly value-driven healthcare market, it is important to establish standards to serve as a reference for future improvement efforts. The father of lean manufacturing, Taichi Ohno, perhaps put it best when he stated, “Without standards, there can be no improvement” . The purpose of this study, therefore, was to establish reference procedure lengths for 1-level, 2-level, and 3-level ACDFs at both teaching and non-teaching institutions and to describe methods for using these data to advance surgical process improvement initiatives.
Materials & Methods
The Institutional Review Boards of Virginia Mason Medical Center, Seattle, Washington, and St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, approved this study. We retrospectively analyzed consecutive ACDF procedures from a period spanning 35 months at two different spine centers (July 2013 to May 2016), one being a resident teaching institution (RT) and the other a non-teaching institution (NT). Surgeons at the NT institution regularly worked with a physician’s assistant whose role in an ACDF was limited to retraction and surgical site closure. Cases for inclusion were identified based on the surgeon-provided case description in the electronic medical record. Procedures that involved one or more corpectomies, hardware revisions, washouts for infection or hematoma, a second stage posterior procedure immediately preceding or following the ACDF, or disc arthroplasty were excluded from the analysis. Adjacent segment ACDFs that did not include hardware revision were included. Collected case variables included the operating surgeon, procedure length from skin incision to skin closure, patient age, the number of levels treated, whether or not the patient was admitted through the emergency department, the hospital length of stay (LOS) from skin incision to discharge, returns to the emergency department within 30 days (RED30), hospital readmissions within 30 days (RAD30), returns to the operating room within 30 days (ROR30), mortality within 30 days (MOR30), and whether hospital discharge was to home, acute rehabilitation facility, or skilled nursing facility. The decision was made not to collect more detailed patient demographics or to perform univariate or multivariate analyses based on demographics as we felt these analyses might distract from the purpose of the study, which was not to determine causes or predictors of extended ACDF procedure length, but rather set initial benchmarks for ACDF procedure length, then to describe methods for using these benchmarks to advance surgical process improvement initiatives.
Cases were divided into groups based on RT or NT institution and the number of levels treated. Mean case lengths were then calculated for each surgeon. Surgeon mean case lengths were compared graphically, and overall mean case lengths were calculated for...(More)
For more info please read, Establishing a Reference Procedure Length for Anterior Cervical Fusions, by Cureus