Neurosurgery
-
The passage of the Affordable Care Act saw the creation of Accountable Care Organizations (ACOs), a new approach to healthcare delivery moving from fee-for-service toward population health. This paper presents a case study of the Memorial Hermann ACO (MHACO), launched in response to the Medicare Shared Savings Program, with goals to align physician and hospital incentives, practice evidence-based medicine, develop care coordination, and increase efficiency. Building blocks included an affiliated primary care network, a clinical integration program (involving shared electronic medical record platforms and quality data reporting), and significant investments in information technology. ⋯ Although ACOs to date have focused on primary care, the future will increasingly involve specialists. At Memorial Hermann, neurosurgeons took an early role in forming collaborative partnerships with the hospital, and started programs that served as precursors to the ACO model. This paper ends with an overview of ACO development, likely changes going forward, and a discussion of the role of specialists in general, and of neurosurgeons in particular.
-
Radiation-based treatment options of large intracranial arteriovenous malformations (AVM) must balance the likelihood of obliteration with the risk of adverse radiation effects (ARE). ⋯ VS-SRS permitted large volume intracranial AVM to be treated with a low rate of ARE. Further study is needed on dose escalation and decreasing the treatment volume per stage to determine if this will increase the rate of obliteration with this technique.
-
The diagnosis of Cushing disease is based on endocrinological pa-rameters, with no single test being specific. In some patients, dynamic thin-slice sellar magnetic resonance imaging fails to detect a pituitary tumor. ⋯ The incidence of primarily ectopic ACTH-secreting adenomas in this series was 6%. In cases of negative MRI findings, an ectopic ACTH-secreting adenoma should be taken into account. 68 Ga DOTATATE positron emission tomography/computed tomography may identify ectopic pituitary adenomas. Hypophysectomy should always be avoided in primary surgery for CD.
-
Convex-rod derotation may have potential advantages for adolescent idiopathic scoliosis (AIS) correction; however, study of this technique has been limited. ⋯ Compared with concave-rod derotation, convex-rod derotation can potentially improve the major-curve corrective rate and tends to reduce the risk of pedicle breach in Lenke type I AIS patients.
-
The importance of outcome measures is steadily increasing due to the rise of "pay for performance" and the advent of population health. In 2007, a quality initiative was started due to poor performance on rankings such as the University Health Consortium (UHC) report card. Inherent to all such efforts are common challenges: how to engage the providers; how to gather and ensure the accuracy of the data; how to attribute results to individuals; how to ensure permanent improvements. ⋯ Infection rates decreased 80%. The program now involves all trainee physicians, advanced practice providers, nurses, and other staff. This paper describes the design, implementation, and results of this effort, and provides a practical guide that may be useful to other groups undertaking similar initiatives.