How should value be defined in spine surgery?

Introduction
In a health care economy with limited resources, providers and consumers of health care services need to be accountable for the end result and the cost of care. The value proposition in health care is an analysis of the benefits of care relative to the direct cost and risk of providing the care. Measurement of benefits and costs is challenging, and a consensus on the measures that encompass the relevant components of the value equation has not been reached. Traditional outcome measures in orthopedics including survival, radiographic outcomes, and disease-specific outcome tools do not adequately reflect the patient’s health care experience, or the impact of an intervention on health-related quality of life. Similarly, measuring cost of care is complex, and may encompass both direct costs of treatment and alternative treatments, and indirect costs including time from work or family role, loss of productivity, and cost of caretakers.

The value equation may vary depending on the perspective of the stakeholder in the health care economy. Hospitals and facilities providing care may measure outcome and costs by factors that affect their short-term, single admission interaction, including length of stay, implant utilization, and complications. Third-party payors may focus on a timeframe that is longer that a single admission, and may include factors in the value equation such as readmission within 90 days, or cost of outpatient care. Hospital- and payor-based quality measures may be misinterpreted as measures of outcome or value. Length of stay, surgical times, compliance with antibiotic or thromboembolic prophylaxis, and perioperative complications are process measures that may be useful to compare hospital and provider performance when appropriately matched and stratified. However, they are not useful in measuring a patient’s health care experience, or the impact of an intervention on long-term health-related quality of life. In fact, a focus on quality and process measures alone may be misleading in the pursuit of value in health care, and may provide incentive for counterproductive care strategies that serve the measurement system rather than the patient.

The health care provider and the patient measure outcome by the impact of an orthopedic intervention on health-related quality of life (HRQoL). The timeframe for the patient and provider is a lifetime, rather than a single admission. As Porter and Teisberg wrote in 2006, the right goal for health care delivery is superior patient value, which is measured at the level of specific medical conditions. Measurement of outcomes of care needs to reflect the patient’s long-term health care experience, and the impact of one intervention compared with alternatives on the patients self-assessment of HRQoL.