{"id":5257,"date":"2019-02-01T07:00:28","date_gmt":"2019-02-01T07:00:28","guid":{"rendered":"http:\/\/www.breecollaborative.org\/?p=5257"},"modified":"2019-02-01T07:00:28","modified_gmt":"2019-02-01T07:00:28","slug":"revised-lumbar-fusion","status":"publish","type":"post","link":"https:\/\/www.qualityhealth.org\/bree\/2019\/02\/01\/revised-lumbar-fusion\/","title":{"rendered":"Introducing our Revised Lumbar Fusion Bundled Payment Model and Warranty"},"content":{"rendered":"<hr \/>\n<p>For the past year, our <a href=\"http:\/\/www.breecollaborative.org\/topic-areas\/previous-topics\/apm\/\">Accountable Payment Models workgroup<\/a> has been reviewing evidence, hearing from community members, and revising our <a href=\"https:\/\/www.qualityhealth.org\/bree\/wp-content\/uploads\/sites\/8\/2019\/01\/Lumbar-Fusion-Bundle-and-Warranty-Final-2018.pdf\">Lumbar Fusion Bundled Payment Model and Warranty<\/a>. At our recent Bree Collaborative January meeting, members voted to adopt the bundle and warranty. Our goal in this revision was to respond to changes in the evidence but also to make our model more usable for our health care community. Big changes include expanding the scope beyond a single level of fusion and expanding surgical site to include both in- and out-patient. We also added language to be used for contracting as well as detailed procedural and complication codes. During this process we also revised our evidence table, bringing our number of reviewed articles to 123 citations.<\/p>\n<p>We are very grateful for our workgroup members but also for the many community members and professional associations who offered constructive changes so that we were able to create a pragmatic, evidence-based bundled payment model and warranty.<\/p>\n<p>Other notable changes include:<\/p>\n<ul>\n<li><strong>&#8211; Cycle I<\/strong>\n<ul>\n<li>&#8211;\u00a0Adding additional optional patient reported outcomes measures to our previous requirement of PROMIS-10 and Oswestry Disability Index<em>: <\/em>Roland-Morris Disability Scale, EuroQual-5 Dimensions (EQ-5D), Short Form 36 (SF-36), Therapeutic Associates Outcome Score, and\/or a similarly peer-reviewed and validated patient-reported outcome<\/li>\n<li>&#8211;\u00a0Adding to documentation of imaging findings confirming lumbar instability \u201c<em>Previous decompressive surgery requiring significant facetectomies for foraminal decompression that are expected to create instability in the spinal segment<\/em>\u201d<\/li>\n<li>&#8211;\u00a0Replacing the requirement that a physiatrist lead the collaborative team, although this is still preferred, and adding a requirement that a consultation with a physiatrist be obtained to validate that optimal non-surgical care has occurred and that surgery is indicated.<\/li>\n<li>&#8211;\u00a0Adding more specificity to the trial of non-surgical measures prior to surgery (i.e., Risk stratification with the STarT Back tool or similar to inform treatment plan, active physical therapy aimed specifically at patients with lumbar segmental instability, with a program of spinal stabilization and hip mobilization).<\/li>\n<li>&#8211;\u00a0Moving shared decision making to the first cycle.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Cycle II<\/strong>\n<ul>\n<li>&#8211;\u00a0Requiring the care team to complete a pre-operative plan for post-operative return to function and an assessment of the home environment for safety and adequate support to the second cycle.<\/li>\n<li>&#8211;\u00a0Adding two guidelines, the <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK367919\/\">2016 guideline from the National Institute for Health and Care Excellence (NICE)<\/a> and the <a href=\"http:\/\/www.onlinejacc.org\/content\/64\/22\/e77\">2014 ACC\/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery<\/a><\/li>\n<li>&#8211;\u00a0Removing unneeded measurement using patient-reported outcome measures.<\/li>\n<li>&#8211;\u00a0Adding \u201c<em>Providers and facilities are encouraged to examine the safety and efficacy of implanted devices. Devices should be approved by the facility. Implanted devices should be a part of a registry<\/em>.\u201d<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Cycle III<\/strong>\n<ul>\n<li>&#8211;\u00a0Changing the standards for the surgical team and facility to the minimum number of lumbar fusions being 30 per primary or first assist surgeon and 60 per &#8211;\u00a0facility in the previous 12 months.<\/li>\n<li>&#8211;\u00a0Replacing the requirement that surgery be performed in an inpatient facility with the requirement that the facility have sufficient staffing and access to resources to address potential complications.<\/li>\n<li>&#8211;\u00a0Adding requirements to follow the 2018 Bree Collaborative <a href=\"https:\/\/www.qualityhealth.org\/bree\/wp-content\/uploads\/sites\/8\/2018\/09\/Final-Supplemental-Bree-AMDG-Postop-pain-091318-wcover.pdf\">Prescribing Opioids for Postoperative Pain \u2013 Supplemental Guidance<\/a>.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Cycle IV<\/strong>\n<ul>\n<li>&#8211;\u00a0Adding assessment of the home environment for safety and adequate support (e.g. architectural barriers, availability of assistive devices, availability of care companion)<\/li>\n<li>&#8211;\u00a0Adding measurement of patient reported functional outcomes with standard instruments at three months and if possible at 12 months as specified above using the same tools used for initial assessment.<\/li>\n<li>&#8211;\u00a0Adding continuing nicotine avoidance measures for at least three months following surgery.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Quality Standards<\/strong>\n<ul>\n<li>&#8211;\u00a0Adding examples for measurements of evidence-based surgery (e.g., blood count for measures to reduce blood loss and need for transfusion).<\/li>\n<li>&#8211;\u00a0Adding the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Warranty<\/strong>\n<ul>\n<li>&#8211;\u00a0Replacing <em>infection involving implant<\/em> with <em>deep incisional surgical site infection that may involve implant<\/em> at 90 days.<\/li>\n<li>&#8211;\u00a0Removing death from warranty.<\/li>\n<li>&#8211;\u00a0Adding that \u201c<em>the facility performing the surgery must have an agreement with a hospital to manage complications following sur<\/em>gery\u201d and that \u201c<em>the facility will provide information and instructions to the patient to seek treatment at that designated hospital<\/em>.\u201d<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Adding an Appendix C to assist with the contracting process.<\/strong><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><strong>&#8211;\u00a0Adding an Appendix E with procedural and complication codes.<\/strong><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><a class=\"button\" href=\"https:\/\/www.qualityhealth.org\/bree\/wp-content\/uploads\/sites\/8\/2019\/01\/Lumbar-Fusion-Bundle-and-Warranty-Final-2018.pdf\">Read our Bundle and Warranty!<\/a><\/p>\n<p><a class=\"button\" href=\"https:\/\/www.qualityhealth.org\/bree\/wp-content\/uploads\/sites\/8\/2018\/12\/SpineSurgery_EvidenceTable_20181210.xlsx\">Read our Evidence Table!<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>Ginny Weir, MPH<br \/>\nDirector, Bree Collaborative<\/p>\n","protected":false},"excerpt":{"rendered":"For the past year, our Accountable Payment Models workgroup has been reviewing evidence, hearing from community members, and revising our Lumbar Fusion Bundled Payment Model and Warranty. At our recent&#8230;","protected":false},"author":88,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-5257","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"aioseo_notices":[],"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/posts\/5257","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/users\/88"}],"replies":[{"embeddable":true,"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/comments?post=5257"}],"version-history":[{"count":0,"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/posts\/5257\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/media?parent=5257"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/categories?post=5257"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.qualityhealth.org\/bree\/wp-json\/wp\/v2\/tags?post=5257"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}