Outstanding Paper Award Winner Tackles Spine Surgery at ACOs

The winner of the 2018 Outstanding Paper in Surgical Science, presented by The Spine Journal, is a study that documented 90-day spine surgery morbidity, mortality and readmission rates at Medicare Accountable Care Organizations (ACO) and then compared that data with similar outcomes at non-ACO facilities.

Their conclusion? On the basis of three measures ONLY, ACOs are no better nor worse than non-ACOs.

The full study has been published under the title: “Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009-2014),” in the January 2019 edition of The Spine Journal.

Andrew J. Schoenfeld, M.D., M.Sc., orthopedic surgeon at Brigham and Women’s Hospital, Harvard Medical School in Boston, Massachusetts, and co-author told OTW, “ACOs have been heralded as a means to improve quality in healthcare. While some putative benefits have been shown in some scenarios, mostly around primary care, it is unclear that much of an impact would be seen in surgery. We wanted to evaluate this specifically as pertains to elective spine procedures, which are among the most frequently performed interventions in Medicare patients.”

The authors described their methodology and results in this excerpt from their paper, “In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day read-admissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs.”

Dr. Schoenfeld commented to OTW,“The most compelling results rest in the fact that our study failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs.”

“We realize that the results presented here represent but a 5-year period that encompasses the ACO implementation stage and substantive health reform efforts engendered by the ACA [Affordable Care Act]. It is entirely possible that as more organizations form ACOs and current ACOs become more adept at improving healthcare quality and efficiency, demonstrable improvements in postsurgical outcomes may follow.”

“There may be a number of etiologies for the lack of meaningful changes observed at present, including the fact that currently surgical interventions are not a main focus of ACO models and may only be marginally impacted by the organizational changes incentivized. The results of our work indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present and, were improvements in such outcomes a definite aspiration, mechanisms directed at surgical quality would have to be emphasized in ACO models.”