LAUSR

Back pain is the leading international cause of life years lived with disability, and in Australia in 2008–2009 $1.2 billion of healthcare expenditure was attributed to back disorders, with $560 million being for admitted patient costs. However the overall value of these procedures on clinical outcomes and quality of life for Australian patients is not well documented. Furthermore, variation in procedure rates for lumbar spine surgery has recently been noted by the Australian Commission on Safety and Quality in Health Care (ACSQHC) where rates of lumbar decompression procedures across Australia had a fivefold variance, and rates of lumbar fusion procedures had a nearly sevenfold variance. While this variation is likely multifactorial comprising patient related factors, service access and clinician practice, it was also considered that some was potentially clinically unwarranted. As a result, the ACSQHC recommended that a national registry for all patients undergoing lumbar spinal fusion operations be established. Concurrently, musculoskeletal conditions have been listed as a priority domain for the development of clinical quality registries (CQRs) in Australia by the ACSQHC. CQRs collect standardized clinical information regarding a particular condition or disease from multiple institutions for the primary purpose of quality improvement. CQRs differ from registries based on claims data or other proxies of outcome. While these may offer valuable insights, they are not likely to provide the granular data needed to drive clinician-led quality improvement. There are at least 25 prospective spine surgery registries currently operating throughout Europe, North America and the United Kingdom. While some Australian surgeons have participated in the Spine Society of Europe’s Spine Tango Registry, Australia has not had a nationally led spine surgery outcomes registry until now. Sponsored by the Spine Society of Australia (SSA), funded by industry and managed in conjunction with Monash University, the Australian Spine Registry (ASR) pilot was established in 2017 following a clinician expression of interest process, and commenced data collection in January 2018. The pilot aims to assess the feasibility and methodology of establishing a clinical quality spine registry in Australia. The ASR Steering Committee is comprised of SSA membership, surgeons participating in the pilot, Monash University and with funders potentially as non-voting members. Using customized commercial software, the registry will initially collect information from participating orthopaedic surgeons and neurosurgeons across 10 public and private settings in multiple states. The registry data is owned by the SSA, and all external requests for data (beyond the initial pilot) will be in accordance with the ASR Data Request Policy, which is aligned with other Monash clinical registries and the ACSQHC’s Operating Principles (2008). The ultimate aim of the ASR is to enhance the quality of care for spine surgery patients via: • Monitoring of individual patient’s postoperative progress. • Providing a tool for individual surgeons to complete audits of their surgery. • Obtaining data for implant and prosthesis surveillance. • Monitoring trends in surgical approach and outcomes for spine surgery. • Providing an infrastructure to assist specific research and targeted studies. • Determining the results and functional effectiveness of specific spine surgeries in a ‘real world’ setting. The ASR collects patient demographic, clinical and comorbidity data; surgical details and complications; and patient reported outcome measures (PROMs). PROMs are collected prior to surgery and at 6, 12 and 24 months post-operatively using the same collection tools as the major international registries (the EuroQol five dimensions, the Oswestry Disability Index (ODI), and the Neck Disability Index). Data collection is via multiple methods, a strategy that is recommended internationally to optimize data capture, including web-based direct-entry by clinicians and their affiliated staff, email and paper-based forms for patients. The dataset of the ASR has been mapped to the International Consortium of Health Outcomes Measurement’s Low Back Pain Standard Set 2015, to facilitate international harmonization and benchmarking of data. Similar to the British Spine Registry, the ASR proposes to initially define quality measures for only a few specific procedures – discectomies, primary anterior cervical discectomy with fusion and L4-5 degenerative spondylolysthesis. Outcome measurement for the ASR is based on that defined by spine registries internationally for lumbar surgery, with the primary endpoint being a minimum clinically important difference in the ODI. Spine registries internationally have also developed predictive models of patient factors that determine successful surgical outcomes and medical complications reflecting the importance of patient factors in surgery success. The establishment of the ASR presents challenges and opportunities. For example, adjusting for patient and disease factors is important, and a locally applicable model for this needs to be determined to support benchmarking of outcomes. Quality assurance of data will initially be undertaken via practice/medical record audits of participating surgeons, however in the longer term periodic audits of hospital health information system reports will need to be