Functional Status After Lumbar Surgery

Measure Specification

Mechanical low back pain (LBP) remains the second most common symptom-related reason for seeing a physician in the United States. Of the US population, 85% will experience an episode of mechanical LBP at some point during their lifetime. Fortunately, the LBP resolves for the vast majority within 2-4 weeks. For individuals younger than 45 years, mechanical LBP represents the most common cause of disability and is generally associated with a work-related injury.

For individuals older than 45 years, mechanical LBP is the third most common cause of disability, and a careful history and physical examination are vital to evaluation, treatment, and management. Overall, spine surgery rates have declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries.

Complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.

95 (95% confidence interval [CI], 2.50- 3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.

The MNCM Spine Surgery Measure development workgroup developed patient reported outcome measures for two populations of patients undergoing different lumbar spine procedures, a more complex procedure (lumbar fusion) and a second procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. In 2018, the development workgroup reconvened and redesigned the measure construct to a target-based measure and additionally expanded the denominator for this measure to include all lumbar discectomy laminectomy procedures Rationale for measure construct and calculation change: The target was derived from a study “Determination of the Oswestry Disability Index score equivalent to a "satisfactory symptom state" in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry- based study”.

vanHooff, ML et al Spine J. 2016 Oct;16(10):1221-1230. Patient Acceptable Symptom State (PASS), the highest level of symptom beyond which patients consider themselves well. PASS was compared to post-op ODI to determine an equivalent ODI threshold. ODI score less than or equal to 22 indicates the achievement of an acceptable symptom state and can be used as a criterion for treatment success.

[AUC]: 0.89 [sensitivity: 78.3%, specificity: 82.1%] for 1 year follow-up]. The OR benchmark of improvement (30) derived from MNCM data (3 years); the average improvement in points of patients that did achieve the target of less than or equal to 22. Rationale for the expansion of the denominator and addition of exclusions: During the original development of this measure, the intent was to have a homogeneous population procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation.

This strategy did not translate well from ICD-9 to ICD-10 diagnosis codes and the volume of eligible denominator patients dropped significantly. In 2018, the MNCM development workgroup reconvened for measure construct redesign and adopted a broader denominator population; all applicable discectomy laminectomy procedure codes and not limited by a type of diagnosis (includes all).

With this decision, the workgroup decided to adopt the same exclusions for the spine fusion population and added exclusions for spine related cancer, acute fracture or infection, idiopathic or congenital scoliosis.

Journal of Neurosurgery guidelines indicate that there is no evidence that conflicts with the previous recommendations published in the original version of the guideline. This recommendation is for the use of a reliable, valid and responsive outcomes instrument to assess functional outcome in lumbar spinal fusion patients. It is recommended that when assessing functional outcome in patients treated for low-back pain due to degenerative disease, a reliable, valid, and responsive outcomes instrument, such as the disease-specific Oswestry Disability Index (ODI), be used (Level II evidence).

This measure contains two strata defined by two submission criteria. This measure produces two performance rates which are used for a weighted average. There are 2 Submission Criteria for this measure: 1) Functional status improvement at three months post lumbar discectomy/laminectomy procedure OR 2) Functional status improvement at one year post lumbar fusion procedure This measure will be calculated with 2 performance rates: 1) Percentage of lumbar discectomy/laminectomy procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.

1a) at three months (6 to 20 weeks) postoperatively 2) Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively A weighted average, which is the sum of the performance numerator values divided by the sum of performance denominator values, will be used to calculate performance.

For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period. The most recent quality data code will be used if the measure is submitted more than once. This measure is a target-based measure with two ways to meet the numerator; either a postoperative ODI score that is less than or equal to 22 OR an improvement of 30 points or greater from the preoperative to postoperative score.

It is expressed as a proportion or rate. Patients having received a lumbar discectomy/laminectomy or fusion procedure who are not assessed for functional status postoperatively remain in the denominator and are considered as not meeting the target. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures to be utilized for performance calculation.

Electronic use of the Oswestry Disability Index (ODI) tool is no longer available free of charge. A paper alternative is available at no cost.