The science of neurosurgical practice: Experts discuss importance of quality improvement, clinical research, patient care

In their Introduction, the editors -- Anthony L. Asher, MD, FAANS, FACS (Carolina Neurosurgery and Spine Associates & Carolinas Medical Center, Charlotte); Paul C. McCormick, MD, MPH, FAANS, FACS (Columbia University College of Physicians and Surgeons, New York); and Douglas Kondziolka, MD, FAANS (New York University, New York) -- speak of a parallel shift from an era in which medical knowledge was generated by a small percentage of researcher-physicians to a time in which most physicians will actively participate in the collection of new facts, their interpretation, and the generation of new knowledge. This activity will be made possible by physicians' ability to deposit, access, and compare clinical data in huge long-term prospective databases of medical disorders and treatments.

"Our specialty is now engaged in an unprecedented cooperative effort that aims to create a new integrative culture of neurosurgical practice for the purpose of improving care," notes Dr. Asher. "Tremendous scientific and economic potential resides untapped within our routine clinical activities. The methods to realize that potential now exist. The promise of those methods can only be realized through concerted effort and organized action. If neurosurgeons choose to embrace practice science as an essential feature of modern neurosurgical practice, we will help meet the challenges of creating a sustainable health-care system, and we will also define the relevance of neurosurgery within the broader realm of medicine and society."

In the field of neurosurgery, several professional societies have joined together to advance the quality of patient care and to serve the research needs of neurosurgeons and other health-care stakeholders. To this end, a national practice data collection, analysis and reporting platform -- the National Neurosurgery Quality and Outcomes Database (N2QOD) -- has been initiated. This issue of Neurosurgical Focus contains articles describing N2QOD as well as the overall new trend in professional neurosurgery -- what the editors term the "science of neurosurgical practice" -- from its beginnings to its projected future. Specific topics in the January issue of Neurosurgical Focus include the following:

Health-care reform, as exemplified in the Patient Protection and Affordable Care Act, according to Rachel Groman and Koryn Rubin, "aims to change the U.S. health-care system from one that rewards quantity to one that rewards better value through the use of performance measurement." The authors discuss current barriers to this shift toward better care as well as initiatives created by both the federal government and physician societies in ensuring accountability and delivery of high-quality care to patients.

Peter Angevine, MD, MPH, FAANS, and Dr. Paul C. McCormick discuss the science and methods used to measure clinical practice. They also speak of the benefits accrued from physicians' ease of access to the extensive outcomes research contained in clinical registries.

In 1987 the Gamma Knife® first became available in North America, at the University of Pittsburgh, ushering in the practice of radiosurgery. Since that time, the university has documented the techniques of this procedure and outcomes in patients who have undergone Gamma Knife surgery at that institution. Oren Berkowitz, PhD, MSPH, PA-C, and colleagues review how the school's clinical registry evolved and how it has facilitated publication of numerous works on the University of Pittsburgh experience, advancing knowledge of the techniques and outcomes of radiosurgery.

Matthew McGirt, MD, and colleagues describe an overview of their experience at the Vanderbilt Spine Center (Vanderbilt University Medical Center). Here, outcomes data have been collected during routine spine care and recorded in a prospective fashion in a longitudinal registry. These data are used for learning and quality improvement; documentation of safety and effectiveness of care; and research into the comparative effectiveness of different procedures.

In March 2012, the N2QOD, sponsored by the AANS with the support of the Congress of Neurological Surgeons (CNS), Society of Neurological Surgeons, American Board of Neurological Surgery and AANS/CNS Joint Section on Spine & Peripheral Nerves, began enrolling patients in its pilot project, an Internet-based database of cases of lumbar spine disorders. When fully functional, the N2QOD will expand its coverage to all facets of neurosurgery and serve as a longitudinal outcomes registry that will provide neurosurgeons with "a quality measurement and feedback system that utilizes meaningful patient-centered data. . . . Providers will have the opportunity to learn which diseases, which patient groups, and which treatments are most effectively treated with surgery and identify areas for improving the quality of neurosurgical and spine care." Articles in this issue by Drs. Asher, McCormick, and McGirt with their colleagues describe the development and overall purpose of the N2QOD, the pilot project, and regulatory considerations for prospective registries such as the N2QOD.

Nathan Selden, MD, PhD, FAANS, and coworkers discuss the future of neurosurgical practice-based science as it relates to neurosurgical training and practice as well as to improvements in patient-care delivery and compliance with regulatory mandates.

All papers are published online Jan. 1, 2013 online in Neurosurgical Focus, Vol. 34, No. 1, (http://thejns.org/toc/foc/34/1). Papers in Neurosurgical Focus are free to the public.