Editorial: Value-Based Healthcare in Skull Base Surgery

Value in Healthcare

Over the past two decades, providers, payers, and healthcare systems have placed an increasing emphasis on value-based healthcare (VBHC). Value in healthcare is defined as quality of service divided by cost. As healthcare costs continue to rise and payments models continue to primarily be fee-for-service, there is an increasing emphasis on maximizing quality, as determined by patient satisfaction and objective outcomes, as well as decreasing costs. Large-scale initiatives were developed to improve quality in acute coronary syndromes and central line-associated infection, among other more common hospital conditions. The Institute of Medicine outlined that care should be safe, effective, timely, efficient, equitable, and patient-centered. ¹ Skull base pathologies, although generally less common, can result in significant morbidity and disability, translating into long-term effects on patient quality of life and healthcare-associated costs. Providers of all subspecialties are increasingly recognizing the importance of assessing how the value equation can be optimized in their respective practice.

NASBS Value-Based Healthcare Committee Formation and Efforts

In 2016, the Value-Based Healthcare Task Force was created within the North American Skull Base Society (NASBS) to promote education, research, and collaboration within the society for VBHC in skull base surgery. In 2020, the task force achieved full NASBS committee standing. Over the last 5 years, through regular meetings and active discussion, the committee narrowed its prior, ongoing, and future efforts into three primary areas: (1) outcome tracking and benchmarking , (2) educational resources in VBHC , (3) promoting research in VBHC .

There is widespread recognition that quality improvement must be data-driven. The concept of a Learning Health System , as initially defined by the Institute of Medicine, is a system in which “science, informatics, incentives, and culture are aligned for continuous improvement and innovation.” ² Therefore, we believe that each NASBS member and institution should strive to track and analyze their surgical outcomes in order to set benchmarks for success. There are several modular levels in which the committee can theoretically assist in this regard. At a rudimentary level, the committee believes we must develop a core set of outcome measures for different skull base pathologies. The VBHC has ongoing efforts to define these core outcomes. As a second level, for members without established robust data-acquisition mechanisms, the committee is evaluating development of resources and informatics tools that each member institution can adopt in their practice to help track surgical outcomes. At a third tier, the VBHC committee discussed aggregating outcome data, but concerns regarding logistics, resources, and data sensitivity were felt as major barriers toward implementation. The committee believes it is paramount that our efforts promote member collaboration rather than competition.

The second area of ongoing committee efforts is providing educational resources in VBHC. Potential efforts in this area discussed included curation of existing skull base surgery practice guidelines in the form of care pathways, with the goal of sharing strategies and practice experience among NASBS members. Care pathways are widely successful in various areas of medicine to provide more consistent application of best available scientific evidence, reduce errors and unwanted practice variation, and facilitate local-level processes to maximize resource efficiency and improve quality. ^{3 4} Many NASBS member institutions have actively developed and implemented pathology-specific care pathways. We recognize the development of care pathways is time consuming, which presents a significant barrier to development and implementation. As part of the committee goal to provide educational resources in VBHC, the committee established the NASBS iCARE ( i nstitutional CARE pathway) Archive, a member access only, NASBS-hosted repository of member institution care pathways. This will serve as a great resource for members to develop their own care pathways, evaluate their existing care pathways, and promote the spread of knowledge and best practices.

The third area of ongoing committee efforts is promoting new data and research in the area of VBHC. One large-scale effort in this area was the multi-institutional data collaborative regarding antibiotic prophylaxis in skull base surgery, the results of which are published in this issue by Saleh et al. This project laid the framework for future multi-institutional data collaborative studies through the recruitment of member institutions, regulatory approval and handling of protected health information, and legal considerations between member institutions. The other primary effort in this area is the establishment of this special issue in our society's journal, Journal of Neurological Surgery Part B , to promote VBHC research in skull base surgery.

Special Issue on Value-Based Healthcare

This special issue called for article submissions examining innovations in value-based skull base care, such as (1) reducing costs involved in surgical materials or implants, unnecessary tests or interventions, inappropriate medications; (2) reducing length of stay (LOS) or hospital readmissions; (3) reducing perioperative complications such as vascular injury, cerebrospinal fluid (CSF) leak, nerve injuries, and venous thromboembolism; (4) improving patient selection through optimization algorithms, predictive analytics, artificial intelligence; (5) evaluating patient-centric or patient-reported outcomes measures including quality of life related to skull base disease; (6) improving patient satisfaction through educational and patient support initiatives; (7) protocols addressing safety, efficacy, and efficiency through operating room or enhanced recovery after surgery protocols, care pathways, or use of telehealth.

In this special edition, Saleh et al report results of the first NASBS multi-institutional data collaboration, with 15 NASBS institutions contributing data on the risk of meningitis and sinusitis after endoscopic endonasal sellar and parasellar surgery, demonstrating that additional postoperative oral antibiotics did not decrease the risk of infection. They also share insight on the experience with the process and recommendations for the NASBS going forward. Two studies target patient satisfaction: Greven et al present patient-reported satisfaction results with telemedicine consults for new pituitary tumors requiring surgery and Potter et al identify predictive risk factors for increased opioid use after skull base open craniotomies including history of anxiety/depression, preoperative opioid use or history of migraines, younger age, and more extensive muscle dissection. Two studies perform risk assessment that can guide patient selection: Sukys et al utilize a large national surgical database to show that American Society of Anesthesiologists score and modified Frailty Index can predict complications after endoscopic transsphenoidal resection of a pituitary adenoma, and Jimenez et al utilize a machine learning algorithm to predict risk of prolonged LOS, high hospital charges, and discharge disposition after skull base meningioma surgery. Three studies target cost reduction in skull base care. Benjamin et al report on a postoperative endocrinopathy management protocol after pituitary adenoma surgery that led to decreased laboratory costs without any increase in LOS or readmission. McDowell et al demonstrate that the addition of dural sealants did not reduce postoperative CSF leak after endoscopic endonasal skull base surgery. Conversely, Asmaro et al demonstrate that, in patients undergoing endoscopic transsphenoidal resection of sellar lesions, successful results can be achieved without the use of nasal packing when free mucosal grafts or nasoseptal flaps are covered with dural sealant. Two studies discuss initiatives to reduce complications. Choby et al review nasal preservation techniques to reduce morbidity associated with endoscopic skull base surgery. Benedict et al demonstrate the use of fluorescein injection into a lumbar subarachnoid drain postoperatively can be effective option to detect the presence of a postoperative CSF leak. Two studies target reducing postoperative readmission and unnecessary resource utilization, Harary et al identified reasons for phone calls or messages and emergency department visits prior to the first postoperative visit after endoscopic endonasal surgery, with nasal care, appointment scheduling, and symptoms/medication questions as most common questions. Ghiam et al present a multidisciplinary postoperative care pathway to reduce readmissions after endoscopic transsphenoidal pituitary adenoma surgery. Finally, two studies evaluate radiographic initiatives to improve quality: Kirsch et al discuss early detection of meningoencephaloceles in patients presenting with spontaneous meningitis and Patel et al evaluate the utility of intraoperative magnetic resonance imaging to improve extent of resection in pituitary adenoma surgery.