Sir,

We would like to reflect on growing misguided perception that nationwide databases and registries would improve both quality of surgical performance and lower healthcare costs. This theme has been led by paradigm shift from value for services toward the outcome-based reimbursement.[ 5 ]

We had a patient with a prominent left L4-5 disc herniation as a result of work-related injury, which presented itself with a near complete foot drop. An urgent surgical intervention, through microscopic left L4-5 microdiscectomy performed by author, led to a complete neurologic recovery.

This case represents a superb surgical outcome that achieved a complete regain of neurological function. However, under influence by his attorney to achieve financial gains, patient continued to report subjective pain that allowed him and his attorney to collect workers compensation.

The quality assessment score for this patient would reflect a poor outcome for the intervention, and negatively reflect surgeon's performance score. An unfair subjectivity of standardized benchmark in patient-reported status, such as pain, inability to work, and unsatisfactory quality of life,[ 4 ] ignore the fundamental objective measures related to neurosurgical interventions.

A value of neurosurgical intervention should be determined by a variety of measures with a greater emphasis on objective measures for performance rather than an objective perception of patient's experience.[ 1 ] Similar to other professions, teacher's abilities are measured by students test scores. The engineers and architects are evaluated by structures durability and material cost effectiveness.

A notion of high cost continues to be a major deterrent in collecting objective outcome data. A great value in patient surveys remains invaluable for enhancing quality and provide feedback for staff training, and focusing operational resources by examining strength and weaknesses of hospital facility, as perceived by patients.

In the US, a complex multi-payer system accounts for 80% greater non-clinical service expenses.[ 3 ] Soaring healthcare costs have led to numerous attempts to determine driving mechanism of continuous expenditure growth in the US. The Physicians have become a target of misguided perception of fee distribution, where a surgeon fee was around 20% of insurance reimbursement to the hospital for procedure and hospital stay. The US Physicians’ wages account for just 8.6% of all healthcare expenditures.[ 6 ]

Bohl et al. emphasize utility of nationwide database and warn of serious limitations that generate confounding results and inability to provide useful clinical decision-making tool when compared to prospective and randomized studies.[ 2 ] These registries are not designed to any specialty specifications. Thus, they are missing detailed information for determining severity and complexity of surgical cases, and anticipation of recovery from adverse events.

We are hoping that this piece stimulates Neurosurgeons to push for objective evaluation of their work as it had been practiced by many other industries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Berwick DM. Measuring surgical outcomes for improvement: Was Codman wrong?. JAMA. 2015. 313: 469-70

2. Bohl DD, Singh K, Grauer JN. Nationwide Databases in Orthopaedic Surgery Research. J Am Acad Orthop Surg. 2016. 24: 673-82

3. Jiwani A, Himmelstein D, Woolhandler S, Kahn JG. Billing and insurance-related administrative costs in United States’ health care: Synthesis of micro-costing evidence. BMC Health Serv Res. 2014. 14: 556-

4. Parker SL, McGirt MJ, Bekelis K, Holland CM, Davies J, Devin CJ. The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale. Neurosurg Focus. 2015. 39: E4-

5. Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N Engl J Med. 2016. 374: 504-6

6. Last accessed 2017 Aug 05. Available from: https://www.jacksonhealthcare.com/media-room/news/us-physician-compensation-among-lowest-of-western-nations/.