Determining the quality and effectiveness of surgical spine care: patient satisfaction is not a valid proxy

Background contextGiven the unsustainable costs of the US health-care system, health-care purchasers, payers, and hospital systems are adopting the concept of value-based purchasing by shifting care away from low-quality providers or hospitals. Legislation now allows public reporting of these quality rankings. True measures of quality, such as surgical morbidity and validated questionnaires of effectiveness, are burdensome and costly to collect. Hence, patients' satisfaction with care has emerged as a commonly used metric as a proxy for quality because of its feasibility of collection. However, patient satisfaction metrics have yet to be validated as a measure of overall quality of surgical spine care.PurposeWe set out to determine whether patient satisfaction is a valid measure of safety and effectiveness of care in a prospective longitudinal spine registry.Study designProspective longitudinal cohort study.Patient populationAll patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center.Outcome measuresPatient-reported outcome instruments (numeric rating scale [NRS], Oswestry disability index [ODI], neck disability index [NDI], short-form 12-item survey [SF-12], Euro-Qol-5D [EQ-5D], Zung depression scale, and Modified Somatic Perception Questionnaire [MSPQ] anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care.MethodsAll patients undergoing elective spine surgery for degenerative conditions over a 6-month period at a single medical center were enrolled into a prospective longitudinal registry. Data collected on all patients included demographics, disease characteristics, treatment variables, readmissions/reoperations, and all 90-day surgical morbidity. Patient-reported outcome instruments (NRS, ODI, NDI, SF-12, EQ-5D, Zung depression scale, and MSPQ anxiety scale), return to work, patient satisfaction with outcome, and patient satisfaction with provider care were recorded at baseline and 3 months after treatment. Receiver-operating characteristic (ROC) curve analysis was performed to determine whether extent of improvement in quality of life (SF-12 physical component summary [PCS]) and disability (ODI/NDI) accurately predicted patient satisfaction versus dissatisfaction. Standard interpretation of area under the curve (AUC) was used: less than 0.7, poor; 0.7 to 0.8, fair; and greater than 0.8, good accuracy. Multivariate logistic regression analysis was performed to determine if surgical morbidity (quality) or improvement in disability and quality of life (effectiveness of care) were independently associated with patient satisfaction.ResultsFour hundred twenty-two (84%) patients completed all questionnaires 3 months after surgery during the reviewed time period (mean age 55±14 years). Lumbar surgery was performed in 287 (68%) and cervical surgery in 135 (32%) patients. There were 51 (12.1%) 90-day complications, including 21 (5.0%) readmissions and 12 (2.8%) return to operating room. Three hundred fifty-eight (84.8%) patients were satisfied with provider care and 288 (68.2%) with their outcome. Satisfaction with provider care: In ROC analyses, extent of improvement in quality of life (SF-12) and disability (ODI/NDI) differentiated satisfaction versus dissatisfaction with care with very poor accuracy (AUC 0.49–0.69). In regression analysis, 3-month morbidity (odds ratio [95% confidence interval]: 1.45 [0.79–2.66]), readmission (0.66 [0.24–1.80]), improvement in quality of life (SF-12 PCS), or improvement in general health (health transition index) were not associated with satisfaction with care. Satisfaction with outcome: In ROC analyses, improvement in quality of life (SF-12) and disability (ODI/NDI) failed to differentiate satisfaction with good accuracy (AUC 0.76). Neither 90-day morbidity (1.05 [0.46–2.34]) nor 90-day readmission (0.27 [0.04–2.04]) was associated with satisfaction with outcome in regression analysis.ConclusionsPatient satisfaction is not a valid measure of overall quality or effectiveness of surgical spine care. Patient satisfaction metrics likely represent the patient's subjective contentment with health-care service, a distinct aspect of care. Satisfaction metrics are important patient-centered measures of health-care service but should not be used as a proxy for overall quality, safety, or effectiveness of surgical spine care.     

Discovery of an Anion-Dependent Farnesyltransferase Inhibitor from a Phenotypic Screen

By employing a phenotypic screen, a set of compounds, exemplified by 1, were identified which potentiate the ability of histone deacetylase inhibitor vorinostat to reverse HIV latency. Proteome enrichment followed by quantitative mass spectrometric analysis employing a modified analogue of 1 as affinity bait identified farnesyl transferase (FTase) as the primary interacting protein in cell lysates. This ligand-FTase binding interaction was confirmed via X-ray crystallography and temperature dependent fluorescence studies, despite 1 lacking structural and binding similarity to known FTase inhibitors. Although multiple lines of evidence established the binding interaction, these ligands exhibited minimal inhibitory activity in a cell-free biochemical FTase inhibition assay. Subsequent modification of the biochemical assay by increasing anion concentration demonstrated FTase inhibitory activity in this novel class. We propose 1 binds together with the anion in the active site to inhibit farnesyl transferase. Implications for phenotypic screening deconvolution and HIV reactivation are discussed.     

Investigating eight- to nine-year-olds’ self-regulatory self-talk in the context of their classroom tasks

Self-talk has been recognised as an important tool used by children to regulate their thinking and behaviour. Existing studies typically characterise children's self-talk according to broad categories that do not allow for investigation of self-regulatory aspects of children's internalised self-talk. The findings reported in this paper are based on a pilot study aimed at eliciting information on self-talk that eight- to nine-year-olds employ in the context of their classroom tasks and at a stage when the children's self-talk is largely internalised. The findings offer useful insights into the types of self-regulatory self-talk employed by children in the classroom and suggest that these aspects should be considered in the characterisation and study of children's self-talk.     

Contrasting selected reproductive challenges of today with those of antiquity—the past is prologue

Viewing human history through a medical lens provides a renewed appreciation for today’s vexing reproductive challenges, as some modern dilemmas are actually continuations of similar challenges experienced long ago. Certainly there are many examples of assisted fertility therapy that were entirely theoretical only a generation ago, but have become commonplace in modern practice and society. In particular posthumous birth and infertility have, over time, been the focus of compelling social interest, occasionally even impacting national security and dynastic succession. While the concepts have remained static, the tools available to extend and improve reproductive success have changed radically. Appropriately regarded as confidential and private, an individual’s reproductive details are typically impervious to formal study. Yet, archival sources including ancient literature and formal court records can occasionally provide evidence of otherwise deeply personal concerns of a different era. Our assessment finds the issues, worries, and desires of patients of antiquity to align closely with contemporary reproductive challenges. Because children and family have always been central to the human experience, the consequences of reproduction (or the lack thereof) can make substantial imprints upon the cultural, economic, and political landscape—irrespective of civilization or century. In this article, selected motifs are described in a broad historical context to illustrate how challenges of human reproduction have remained essentially unchanged, despite a vast accumulation of knowledge made possible by gains in reproductive science and technology.Plus ça change, plus c’est la même chose.-Jean-Baptiste Alphonse Karr (1808–1890)     

Tapping insertional torque allows prediction for better pedicle screw fixation and optimal screw size selection

Background contextThere is currently no reliable technique for intraoperative assessment of pedicle screw fixation strength and optimal screw size. Several studies have evaluated pedicle screw insertional torque (IT) and its direct correlation with pullout strength. However, there is limited clinical application with pedicle screw IT as it must be measured during screw placement and rarely causes the spine surgeon to change screw size. To date, no study has evaluated tapping IT, which precedes screw insertion, and its ability to predict pedicle screw pullout strength.PurposeThe objective of this study was to investigate tapping IT and its ability to predict pedicle screw pullout strength and optimal screw size.Study designIn vitro human cadaveric biomechanical analysis.MethodsTwenty fresh-frozen human cadaveric thoracic vertebral levels were prepared and dual-energy radiographic absorptiometry scanned for bone mineral density (BMD). All specimens were osteoporotic with a mean BMD of 0.60±0.07 g/cm². Five specimens (n=10) were used to perform a pilot study, as there were no previously established values for optimal tapping IT. Each pedicle during the pilot study was measured using a digital caliper as well as computed tomography measurements, and the optimal screw size was determined to be equal to or the first size smaller than the pedicle diameter. The optimal tap size was then selected as the tap diameter 1 mm smaller than the optimal screw size. During optimal tap size insertion, all peak tapping IT values were found to be between 2 in-lbs and 3 in-lbs. Therefore, the threshold tapping IT value for optimal pedicle screw and tap size was determined to be 2.5 in-lbs, and a comparison tapping IT value of 1.5 in-lbs was selected. Next, 15 test specimens (n=30) were measured with digital calipers, probed, tapped, and instrumented using a paired comparison between the two threshold tapping IT values (Group 1: 1.5 in-lbs; Group 2: 2.5 in-lbs), randomly assigned to the left or right pedicle on each specimen. Each pedicle was incrementally tapped to increasing size (3.75, 4.00, 4.50, and 5.50 mm) until the threshold value was reached based on the assigned group. Pedicle screw size was determined by adding 1 mm to the tap size that crossed the threshold torque value. Torque measurements were recorded with each revolution during tap and pedicle screw insertion. Each specimen was then individually potted and pedicle screws pulled out “in-line” with the screw axis at a rate of 0.25 mm/sec. Peak pullout strength (POS) was measured in Newtons (N).ResultsThe peak tapping IT was significantly increased (50%) in Group 2 (3.23±0.65 in-lbs) compared with Group 1 (2.15±0.56 in-lbs) (p=.0005). The peak screw IT was also significantly increased (19%) in Group 2 (8.99±2.27 in-lbs) compared with Group 1 (7.52±2.96 in-lbs) (p=.02). The pedicle screw pullout strength was also significantly increased (23%) in Group 2 (877.9±235.2 N) compared with Group 1 (712.3±223.1 N) (p=.017). The mean pedicle screw diameter was significantly increased in Group 2 (5.70±1.05 mm) compared with Group 1 (5.00±0.80 mm) (p=.0002). There was also an increased rate of optimal pedicle screw size selection in Group 2 with 9 of 15 (60%) pedicle screws compared with Group 1 with 4 of 15 (26.7%) pedicle screws within 1 mm of the measured pedicle width. There was a moderate correlation for tapping IT with both screw IT (r=0.54; p=.002) and pedicle screw POS (r=0.55; p=.002).ConclusionsOur findings suggest that tapping IT directly correlates with pedicle screw IT, pedicle screw pullout strength, and optimal pedicle screw size. Therefore, tapping IT may be used during thoracic pedicle screw instrumentation as an adjunct to preoperative imaging and clinical experience to maximize fixation strength and optimize pedicle “fit and fill” with the largest screw possible. However, further prospective, in vivo studies are necessary to evaluate the intraoperative use of tapping IT to predict screw loosening/complications.     

Editorial Commentary: When Your Golf Game Is Handicapped by Your Hip

Golf is a common recreational and competitive sport that requires full hip rotation to allow for a smooth and effective swing. Therefore hip impingement and hip osteoarthritis, by limiting rotation, could cause pain in golfers and even encourage them to discontinue the sport. In my opinion, the lead hip in golfers is likely what generally drives the symptoms in the hip, back, or knee. After surgical correction, golfers are able to get back to golf and many experience improved performance.