Clinical StudyPatient reported outcomes following surgery for degenerative spondylolisthesis: comparison of a universal and multi-tier health care system
Introduction
Canada has a publicly funded, national health insurance (NHI) program that delivers care to the entire population. Health care providers are paid fixed amounts for the services they provide and are not permitted to charge additional fees [1]. The United States has a multitier system where health insurance is purchased in the private marketplace, obtained through one's employer or provided by the government through Medicaid or Medicare [1]. Physician compensation is variable depending on patient coverage. Canada provides universal access to health care for its citizens, while nearly one in five Americans is uninsured [2]. Wait times for both specialist consultation and for surgery are reported as major problems for Canadians, while Americans cite high and rising costs of health care and inequalities in access to health services [2], [3], [4].
The Canadian Spine Outcomes and Research Network (CSORN) is a multicenter group of spine centers collecting prospective clinical registry data. The Spine Patient Outcomes Research Trial (SPORT) was a prospective clinical trial designed to investigate management of degenerative lumbar spinal disorders. It included a trial investigating patients with degenerative spondylolisthesis (DS). This trial either randomized patients to surgery or nonoperative management or, for patients not consenting to randomization, enrolled them in an observational cohort [5], [6]
Comparing patient-reported outcomes of these two contrasting health care systems might provide valuable insight into the impact of the different health service delivery processes of each system in the context of a specific diagnostic group. The primary objective of this study was to compare patient-reported outcome measures (PROMs) between a universal and multitier health care system. The secondary objective was to determine independent factors predictive of outcome in surgical DS patients among both cohorts.
Section snippets
Study design
We conducted a retrospective review of prospectively collected data on consecutive patients from a national registry. This was compared with data from a previously published US cohort, the SPORT [5]. CSORN prospectively enrolls consecutive patients with spinal pathology requiring surgical treatment and recruits from 16 tertiary care academic hospitals across Canada. The registry was queried (years 2013–2016) for consecutive patients who underwent surgical treatment of DS. The SPORT surgical DS
Study population
A total of 461 patients achieved 1-year follow-up, including 213 CSORN and 248 SPORT patients. Baseline demographics are reported in Table 2. Compared with the SPORT cohort, the CSORN cohort comprised younger patients (mean age 5.1 years lower), with 7.6% less females. There were more than twice as many active smokers in the CSORN cohort. The number of actively working patients was similar between the cohorts; however, there were more retirees in the SPORT group and more patients who were not
Discussion
This study is novel as it compares baseline and outcome metrics between two health care systems in two different countries: the Canadian universal system and the American multitier model. Golinvaux et al. compared the SPORT DS surgical arm results to a similar group of patients from the American College of Surgeons National Surgical Quality Improvement Program database [13]. The National Surgical Quality Improvement Program database systematically samples patient records from both private and
Conclusion
Surgical DS patients treated in a universal health care system reported considerably higher satisfaction than those treated in a multitier system despite similar baseline clinical and demographic characteristics and comparable postoperative clinical improvement. The universal health care system was identified as an independent predictor of patient satisfaction. Studies that evaluate patient satisfaction after elective surgical treatment of spinal conditions should consider the health care
Acknowledgments
The Spine Patient Outcomes Research Trial (SPORT) is conducted and supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) in collaboration with Trustees of Dartmouth College (U01-AR45444). This manuscript was not prepared in collaboration with investigators of SPORT and does not necessarily reflect the opinions or conclusions of SPORT Investigators.
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Cited by (7)
Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome—Experience with 1001 Patients
2021, World NeurosurgeryCitation Excerpt :The symptom duration (fourth strongest predictor in our analysis) has generally been considered to be associated with negative outcomes. In a recent large retrospective review, Ailon et al.28 found a significant correlation between symptom duration and lower satisfaction for patients surgically treated for degenerative spondylolisthesis, with the most notable difference between a symptom duration of 1–2 years versus 0–6 months (odds ratio, 3.6; 95% confidence interval, 1.3–10.1; P = 0.04). Macki et al.,23 Masuda et al.,29 and Ng et al.30 reported a positive correlation between greater patient satisfaction and a shorter wait before surgery.
The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: A Canadian spine outcomes and research network study
2021, Journal of Neurosurgery: SpineCorrelating Psychological Comorbidities and Outcomes After Spine Surgery
2020, Global Spine Journal
FDA device/drug status: Not applicable.
Author disclosures: TA: Nothing to disclose. JT: Nothing to disclose. NM: Nothing to disclose. HH: Nothing to disclose. KT: Nothing to disclose. YRR: Medtronic (E), outside the submitted work. AY: Nothing to disclose. ND: Nothing to disclose. AG: Nothing to disclose. CB: Nothing to disclose. SC: Nothing to disclose. MHW: Nothing to disclose. AN: Nothing to disclose. JP: Nothing to disclose. MJ: Nothing to disclose. JN: Nothing to disclose. HA: Nothing to disclose. GM: Nothing to disclose. CGF: Royalties from Medtronic (G), consulting for Medtronic (E, paid directly to institution/employer) and Nuvasive (B), and research support from OREF (E, paid directly to institution/employer), AOSpine (E, paid directly to institution/employer), and Medtronic (F, paid directly to institution/employer).
Level of Evidence: 3.