Objective: Visual cohort analysis utilizing electronic health record data has become an important... more Objective: Visual cohort analysis utilizing electronic health record data has become an important tool in clinical assessment of patient outcomes. In this paper, we introduce Composer, a visual analysis tool for orthopedic surgeons to compare changes in physical functions of a patient cohort following various spinal procedures. The goal of our project is to help researchers analyze outcomes of procedures and facilitate informed decision-making about treatment options between patient and clinician. Methods: In collaboration with Orthopedic surgeons and researchers, we defined domain-specific user requirements to inform the design. We developed the tool in an iterative process with our collaborators to develop and refine functionality. With Composer, analysts can dynamically define a patient cohort using demographic information, clinical parameters, and events in patient medical histories and then analyze patient-reported outcome scores for the cohort over time, as well as compare it ...
Background The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly us... more Background The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly used as a general-purpose tool for measuring orthopaedic surgery outcomes. This set of questionnaires is efficient, precise, and correlates well with specialty-specific measures, but impactful implementation of patient-specific data, especially at the point of care, remains a challenge. Although clinicians may have substantial experience with established patient-reported outcome measures in their fields, PROMIS is relatively new, and the real-life meaning of PROMIS numerical summary scores may be unknown to many orthopaedic surgeons. Questions/purposes We aimed to (1) identify a small subset of important items in the PROMIS Physical Function (PF) item bank that are answered by many patients with orthopaedic conditions and (2) graphically display characteristic responses to these items across the physical function spectrum in order to translate PROMIS numerical scores into physical ability levels using clinically relevant, familiar terms. Methods In a cross-sectional study, 97,852 PROMIS PF assessments completed by 37,517 patients with orthopaedic conditions presenting to a tertiary-care academic institution were pooled and descriptively analyzed. Between 2017 and 2020, we evaluated 75,354 patients for outpatient orthopaedic care. Of these, 67% (50,578) were eligible for inclusion because they completed a PROMIS version 2.0 physical function assessment; 17% (12,720) were excluded because they lacked information in the database on individual item responses, and another < 1% (341) were excluded because the assessment standard error was greater than 0.32, leaving 50% of the patients (37,517) for analysis. The PROMIS PF is scored on a 0-point to 100-point scale, with a population mean of 50 and SD of 10. Anchor-based minimum clinically important differences have been found to be 8 to 10 points in a foot and ankle population, 7 to 8 points in a spine population, and approximately 4 points in a hand surgery population. The most efficient and precise means of administering the PROMIS PF is as a computerized adaptive test (CAT), whereby an algorithm intelligently tailors each follow-up question based on responses to previous questions, requiring only a few targeted questions to generate an accurate result. In this study, the mean PROMIS PF score was 41 +/- 9. The questions most frequently used by the PROMIS CAT software were identified (defined in this study as any question administered to > 0.1% of the cohort). To understand the ability levels of patients based on their individual scores, patients were grouped into score categories: < 18, 20 +/- 2, 25 +/- 2, 30 +/- 2, 35 +/- 2, 40 +/- 2, 45 +/- 2, 50 +/- 2, 55 +/- 2, 60 +/- 2, and > 62. For each score category, the relative frequency of each possible response (ranging from "cannot do" to "without any difficulty") was determined for each question. The distribution of responses given by each score group for each question was graphically displayed to generate an intuitive map linking PROMIS scores to patient ability levels (with ability levels represented by how patients responded to the PROMIS items). Results Twenty-eight items from the 165-question item bank were used frequently (that is, administered to more than 0.1% of the cohort) by the PROMIS CAT software. The top four items constituted 63% of all items. These top four items asked about the patient's ability to perform 2 hours of physical labor, yard work, household chores, and walking more than 1 mile. Graphical displays of responses to the top 28 and top four items revealed how PROMIS scores correspond to patient ability levels. Patients with a score of 40 most frequently responded that they experienced "some difficulty" with physical labor, yard work, household chores, and walking more than 1 mile, compared with "little" or "no" difficulty for patients with a score of 50 and "cannot do" for patients with a score of 30. Conclusion We provided a visual key linking PROMIS numerical scores to physical ability levels using clinically relevant, familiar terms. Future studies might investigate whether using similar graphical displays as a patient education tool enhances patient-provider communication and improves the patient experience. Clinical Relevance The visual explanation of PROMIS scores provided by this study may help new users of the PROMIS understand the instrument, feel empowered to incorporate it into their practices, and use it as a tool for counseling patients about their scores.
Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foram... more Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenos...
Study Design: Prospective cohort. Objectives: Patient-Reported Outcome Measurement Information Sy... more Study Design: Prospective cohort. Objectives: Patient-Reported Outcome Measurement Information System (PROMIS) has been validated for lumbar spine. Use of patient-reported outcome (PRO) measures can improve clinical decision making and health literacy at the point of care. Use of PROMIS, however, has been limited in part because clinicians and patients lack plain language understanding of the meaning of scores and it remains unclear how best to use them at the point of care. The purpose was to develop plain language descriptions to apply to PROMIS Physical Function (PF) and Pain Interference (PI) scores and to assess patient understanding and preferences in presentation of their individualized PRO information. Methods: Retrospective analysis of prospectively collected PROMIS PF v1.2 and PI v1.1 for patients presenting to a tertiary spine center for back/lower extremity complaints was performed. Patients with missing scores, standard error >0.32, and assessments with <4 or >...
Study Design: Retrospective cohort study. Objective: To determine the rates of perioperative comp... more Study Design: Retrospective cohort study. Objective: To determine the rates of perioperative complications in patients undergoing anterior cervical discectomy and fusion (ACDF) with allograft versus synthetic cage. Methods: A large national administrative health care database was queried for ACDF procedures performed between 2007 and 2014 using ICD-9 (International Statistical Classification of Diseases, 9th revision) and CPT (Current Procedural Terminology) codes. Cases that utilized structural allograft and synthetic cages were identified via CPT codes. Gender, age, frequency of obesity, cigarette use, diabetes, and number of levels fused were compared between the 2 cohorts using χ2 test. Complications within 90 days were identified via ICD-9 codes and compared between the 2 cohorts. Revision rates within 2 years were noted. Results: A total of 10 648 ACDF cases using synthetic cages and 7135 ACDFs using structural allograft were identified. The demographics between the 2 cohorts ...
Study Design: Systematic review. Objectives: To review, critically appraise, and synthesize evide... more Study Design: Systematic review. Objectives: To review, critically appraise, and synthesize evidence on the use of allogenic stem cell products for spine fusion compared with other bone graft materials. Methods: Systematic searches of PubMed/MEDLINE, through October 31, 2018 and of EMBASE and ClinicalTrials.gov through April 13, 2018 were conducted for literature comparing allogenic stem cell sources for fusion in the lumbar or cervical spine with other fusion methods. In the absence of comparative studies, case series of ≥10 patients were considered. Results: From 382 potentially relevant citations identified, 6 publications on lumbar fusion and 5 on cervical fusion met the inclusion criteria. For lumbar arthrodesis, mean Oswestry Disability Index (ODI), visual analogue scale (VAS) pain score, and fusion rates were similar for anterior lumbar interbody fusion (ALIF) using allogenic multipotent adult progenitor cells (Map3) versus recombinant human bone morphogenetic protein–2 (rhBM...
Objective Visual cohort analysis utilizing electronic health record data has become an important ... more Objective Visual cohort analysis utilizing electronic health record data has become an important tool in clinical assessment of patient outcomes. In this article, we introduce Composer, a visual analysis tool for orthopedic surgeons to compare changes in physical functions of a patient cohort following various spinal procedures. The goal of our project is to help researchers analyze outcomes of procedures and facilitate informed decision-making about treatment options between patient and clinician. Methods In collaboration with orthopedic surgeons and researchers, we defined domain-specific user requirements to inform the design. We developed the tool in an iterative process with our collaborators to develop and refine functionality. With Composer, analysts can dynamically define a patient cohort using demographic information, clinical parameters, and events in patient medical histories and then analyze patient-reported outcome scores for the cohort over time, as well as compare it ...
Objectives. To examine the relationship between the Patient Reported Outcome Measurement Informat... more Objectives. To examine the relationship between the Patient Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and PROMIS Physical Function (PF) scales in patients with spinal pain at a university spine center. Design. Retrospective analysis of prospectively collected patient-reported outcome data at a university spine clinic. Pearson correlation was done to examine the relationship of the PROMIS PF and PROMIS PI scores. Age, gender, and race were analyzed by subgroups on the PROMIS Physical Function and Pain Interference score. Linear regression analyzed predictive relationships. Statistical significance was set at P < 0.05. Results. A total of 1,992 participants completed an assessment, with 1,923 completing the PF CAT and 1,927 the PI CAT. Participants' mean age was 52.8 years (range 5 18-94 years, SD 5 6.5 years). Correlation analysis of the PROMIS PF with the PROMIS PI showed a Pearson correlation value of-0.717 (P < 0.05). There was a strong linear relationship with a high negative correlation between PF CAT and PI CAT. The PI CAT predicted PF CAT scores (b 5-0.707, P < 0.001). Conclusions. For patients with pain from spinal origin, there is a strong negative correlation between self-reported physical function and pain interference related to physical, social, and mental health. The predictive relationship of function from pain scores supports the PROMIS PI being used as an important adjunct measure of physical function in patients with spinal pain.
Background Context-The Patient-Reported Outcomes Information System (PROMIS) instruments are an i... more Background Context-The Patient-Reported Outcomes Information System (PROMIS) instruments are an important advancement in the use of PROs, but need to be evaluated with longitudinal data to determine whether they are responsive to change in specific clinical populations.
Journal of the American Board of Family Medicine : JABFM
Physical therapy (PT) early in the management of low back pain (LBP) is associated with reduction... more Physical therapy (PT) early in the management of low back pain (LBP) is associated with reductions in subsequent health care utilization and LBP-related costs. The objectives of this study were to 1) Examine differences among newly consulting patients with LBP who received a PT referral and those who did not, 2) examine differences between patients who participated in PT to those who did not, and 3) compare the impact of a PT referral and PT participation on LBP-related health care utilization and costs over 1 year. This was a retrospective cohort study using electronic medical records and claims data. Participants were 454 Medicaid enrollees with new LBP consultations (mean age, 40.4 years; SD = 12.0; 70% women). Outcomes included advanced imaging, injections, emergency department visits, opioid prescriptions, surgery and LBP-related costs. Variables associated with a PT consult, PT participation, and subsequent outcomes were evaluated with multivariate models. A total of 251 (55%)...
Patient-reported outcomes (PROs) have traditionally been implemented through a manual process of ... more Patient-reported outcomes (PROs) have traditionally been implemented through a manual process of paper and pencil with little standardization throughout a Healthcare System. Each practice has asked patients specific questions to understand the patient's health as it pertains to their specialty. These data were rarely shared and there has not been a comparison of patient's health across different specialty domains. We sought to leverage interoperable electronic systems to provide a standardization of PRO assessments across sites of care. University of Utah Health is comprised of four hospitals, 12 community clinics, over 400,000 unique annual patients, and more than 5000 providers. The enterprise wide implementation of PROs started in November of 2015. Patients can complete an assessment at home via email, or within the clinic on a tablet. Each specialty has the opportunity to add additional specialty-specific instruments. We customized the interval with which the patient ans...
Computer methods in biomechanics and biomedical engineering, Jan 16, 2018
Finite element analysis has proven to be a viable method for assessing many structure-function re... more Finite element analysis has proven to be a viable method for assessing many structure-function relationships in the human lumbar spine. Several validated models of the spine have been published, but they typically rely on commercial packages and are difficult to share between labs. The goal of this study is to present the development of the first open-access models of the human lumbar spine in FEBio. This modeling framework currently targets three deficient areas in the field of lumbar spine modeling: 1) open-access models, 2) accessibility for multiple meshing schemes, and 3) options to include advanced hyperelastic and biphasic constitutive models.
Systematic review. The aim was to determine the fusion efficacy of allograft and demineralized bo... more Systematic review. The aim was to determine the fusion efficacy of allograft and demineralized bone matrix (DBM) in lumbar instrumented and noninstrumented fusion procedures for degenerative lumbar disorders. A literature search was conducted using the PubMed and Cochrane databases. To be considered, publications had to meet 4 criteria: patients were treated for a degenerative lumbar disorder, a minimum group size of 10 patients, use of allograft or DBM, and at least a 2-year follow-up. Data on the study population, follow-up time, surgery type, grafting material, fusion rates, and its definition were collected. The search yielded 692 citations with 17 studies meeting the criteria including 4 retrospective and 13 prospective studies. Six studies used DBM and 11 employed allograft alone or in the combination with autograft. For the allograft, fusion rates ranged from 58% to 68% for noninstrumented and from 68% to 98% for instrumented procedures. For DBM, fusion rates were 83% for non...
The spine journal : official journal of the North American Spine Society, Jan 18, 2017
Several studies have suggested that lab results have minimal impact on clinical decision-making i... more Several studies have suggested that lab results have minimal impact on clinical decision-making in surgery. Despite the widespread use of preoperative testing in spine surgery and the large volume of posterolateral lumbar fusions (PLFs) being performed each year, no study has assessed the ability of preoperative labs to predict adverse events following PLF. The purpose of this study was to explore the relationship between commonly obtained preoperative lab results and postoperative complications following 1-2 level PLF. This is a retrospective study of prospectively collected data. The 2006-2013 ACS-NSQIP database was employed to identify all patients who underwent 1-2 level PLF. The outcome variables of interest were 30-day postoperative complications, which were assessed as major complications, minor adverse events, and total complications. Demographics, comorbidities, and perioperative characteristics were collected for each patient. Preoperative labs included sodium, BUN, creati...
Study Design: Retrospective case study. Objective: To evaluate the trends and demographics of rec... more Study Design: Retrospective case study. Objective: To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States. Methods: Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient. Results: A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence...
Commonly used exposures in spinal surgery procedures do not allow the surgeon to visualize the po... more Commonly used exposures in spinal surgery procedures do not allow the surgeon to visualize the position of instrumentation in relation to important deep bone, vascular, and neurological structures. This hidden anatomy can be violated in the operative suite without the surgeon's knowledge, causing irreversible harm to patients or jeopardizing fixation of instrumentation. Current intraoperative imaging devices expose both patient and surgeon to harmful radiation. Advances in imaging technology, computers, and operative technique allow the surgeon to visualize hidden anatomy. Several new modalities including computed tomography (CT) and magnetic resonance imaging (MR[) guidance systems, ~nultidimensional intraoperative fluoroscopy, intraoperative Fluoro/CT scanning, and intraoperative magnetic resonance imaging have become available to assist surgeons. Image guided spinal surgery may reduce risks to patients and surgeons while allowing for more accurate instrumentation and resection in complex spinal procedures.
Study Design: Systematic review. Objectives: The primary objective of this systematic review was ... more Study Design: Systematic review. Objectives: The primary objective of this systematic review was to define the change in impairment, disability, and pain following surgical intervention in patients with degenerative cervical myelopathy (DCM). Secondary objectives included to assess the impact of preoperative disease severity and duration of symptoms on outcomes and to summarize complications associated with surgery. Methods: A systematic literature search was conducted to identify prospective studies evaluating the effectiveness and safety of operative treatment in patients with DCM. Outcomes of interest were functional status, disability, pain, and complications. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and the strength of the overall body of evidence was rated using guidelines outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. Results: Of the 385 retrieved citations, 32 met inclusion criteria and...
Objective: To develop recommendations on the timing of surgical decompression in patients with tr... more Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at...
Objectives: After the Food and Drug Administration approved bone morphogenetic protein-2 (BMP) in... more Objectives: After the Food and Drug Administration approved bone morphogenetic protein-2 (BMP) in 2002, BMP was used off-label in the cervical spine to increase bone growth and bony fusion. Since then, concerns have been raised regarding complication rates and safety. This study was conducted to examine the use of BMP in anterior cervical discectomy and fusion (ACDF) in the Medicare population and to determine risk of complications and associated costs within 90 days of surgery. Methods: Patients who underwent ACDF were identified using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision Procedure codes (ICD9-P). Complications were identified using ICD9 diagnostic codes. Charges were calculated as amount billed, and reimbursements were calculated as amounts paid by Medicare. Data for these analyses came from a nationwide claims database. Results: A total of 215 047 patients were identified who had ACDF from 2005 to 2011. For the majority of the procedures (89.0%), BMP was not used. BMP use rose from 11.84% in 2005 to a peak of 16.73% in 2007 before decreasing to 12.01% in 2011. BMP was used 16% more in women than men. BMP use was the highest in the West (13.6%) followed by Midwest (11.8%), South (10.6%), and Northeast (7.5%). There was a higher overall complication rate in the BMP group (2.1%) compared with the non-BMP group (1.9%) (odds ratio [OR] ¼ 1.11, 95% CI ¼ 1.01-1.22). The BMP group also had a higher rate of wound complications (0.98% vs 0.76%, OR ¼ 1.29, 95% CI ¼ 1.12-1.48). In this study population, there was no difference in dysphagia/hoarseness, neurologic, medical, or other complications. During the 90-day perioperative period, BMP surgeries were charged at 17.6% higher than non-BMP surgeries. Conclusions: The use of BMP in ACDF in the Medicare population has decreased since a peak in 2007. The rate of wound and overall complications for BMP use with ACDF was higher than without. Our results regarding dysphagia/hoarseness did not show a statistically meaningful difference, which is in contrast with many other studies. Charges associated with BMP use were higher during the 90-day perioperative period.
Patient-reported outcome measures PROMs are the most widely accepted means of measuring outcomes ... more Patient-reported outcome measures PROMs are the most widely accepted means of measuring outcomes following spine procedures. We sought to determine the current status of worldwide use of PROMs in Latin America (LA), Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) in order to determine the barrier to its full implementation. A questionnaire survey was sent by e-mail to members of AOSpine to evaluate their familiarity and use of PROMs instruments, and to assess the barriers to their use in spine care practice in LA, EU, AP, NA, and ME. A total of 1,634 AOSpine members from LA, EU, AP, NA, and ME answered the electronic questionnaire. The percentage of spine surgeons familiar with the generic health-related quality of life (HRQoL) questionnaire was 71.7%. in addition, 31.9% of respondents did not routinely use any PROMs. The main barriers to implementing PROMs were lack of time to administer the questionnaires (57%) followed by lack of staff to assist in data collection (55%), and the long time to fill out the questionnaires (46%). The routine use of questionnaires was more frequent in NA and EU and less common in LA and ME (p&amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). We found that 31.9% of spine surgeons do not routinely use the PROMs questionnaire. This appears to occur because of lack of knowledge regarding their importance, absence of reimbursement for this extra work, minimal financial support for clinical research, the cost of implementation and lack of concern among physicians.
Objective: Visual cohort analysis utilizing electronic health record data has become an important... more Objective: Visual cohort analysis utilizing electronic health record data has become an important tool in clinical assessment of patient outcomes. In this paper, we introduce Composer, a visual analysis tool for orthopedic surgeons to compare changes in physical functions of a patient cohort following various spinal procedures. The goal of our project is to help researchers analyze outcomes of procedures and facilitate informed decision-making about treatment options between patient and clinician. Methods: In collaboration with Orthopedic surgeons and researchers, we defined domain-specific user requirements to inform the design. We developed the tool in an iterative process with our collaborators to develop and refine functionality. With Composer, analysts can dynamically define a patient cohort using demographic information, clinical parameters, and events in patient medical histories and then analyze patient-reported outcome scores for the cohort over time, as well as compare it ...
Background The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly us... more Background The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly used as a general-purpose tool for measuring orthopaedic surgery outcomes. This set of questionnaires is efficient, precise, and correlates well with specialty-specific measures, but impactful implementation of patient-specific data, especially at the point of care, remains a challenge. Although clinicians may have substantial experience with established patient-reported outcome measures in their fields, PROMIS is relatively new, and the real-life meaning of PROMIS numerical summary scores may be unknown to many orthopaedic surgeons. Questions/purposes We aimed to (1) identify a small subset of important items in the PROMIS Physical Function (PF) item bank that are answered by many patients with orthopaedic conditions and (2) graphically display characteristic responses to these items across the physical function spectrum in order to translate PROMIS numerical scores into physical ability levels using clinically relevant, familiar terms. Methods In a cross-sectional study, 97,852 PROMIS PF assessments completed by 37,517 patients with orthopaedic conditions presenting to a tertiary-care academic institution were pooled and descriptively analyzed. Between 2017 and 2020, we evaluated 75,354 patients for outpatient orthopaedic care. Of these, 67% (50,578) were eligible for inclusion because they completed a PROMIS version 2.0 physical function assessment; 17% (12,720) were excluded because they lacked information in the database on individual item responses, and another < 1% (341) were excluded because the assessment standard error was greater than 0.32, leaving 50% of the patients (37,517) for analysis. The PROMIS PF is scored on a 0-point to 100-point scale, with a population mean of 50 and SD of 10. Anchor-based minimum clinically important differences have been found to be 8 to 10 points in a foot and ankle population, 7 to 8 points in a spine population, and approximately 4 points in a hand surgery population. The most efficient and precise means of administering the PROMIS PF is as a computerized adaptive test (CAT), whereby an algorithm intelligently tailors each follow-up question based on responses to previous questions, requiring only a few targeted questions to generate an accurate result. In this study, the mean PROMIS PF score was 41 +/- 9. The questions most frequently used by the PROMIS CAT software were identified (defined in this study as any question administered to > 0.1% of the cohort). To understand the ability levels of patients based on their individual scores, patients were grouped into score categories: < 18, 20 +/- 2, 25 +/- 2, 30 +/- 2, 35 +/- 2, 40 +/- 2, 45 +/- 2, 50 +/- 2, 55 +/- 2, 60 +/- 2, and > 62. For each score category, the relative frequency of each possible response (ranging from "cannot do" to "without any difficulty") was determined for each question. The distribution of responses given by each score group for each question was graphically displayed to generate an intuitive map linking PROMIS scores to patient ability levels (with ability levels represented by how patients responded to the PROMIS items). Results Twenty-eight items from the 165-question item bank were used frequently (that is, administered to more than 0.1% of the cohort) by the PROMIS CAT software. The top four items constituted 63% of all items. These top four items asked about the patient's ability to perform 2 hours of physical labor, yard work, household chores, and walking more than 1 mile. Graphical displays of responses to the top 28 and top four items revealed how PROMIS scores correspond to patient ability levels. Patients with a score of 40 most frequently responded that they experienced "some difficulty" with physical labor, yard work, household chores, and walking more than 1 mile, compared with "little" or "no" difficulty for patients with a score of 50 and "cannot do" for patients with a score of 30. Conclusion We provided a visual key linking PROMIS numerical scores to physical ability levels using clinically relevant, familiar terms. Future studies might investigate whether using similar graphical displays as a patient education tool enhances patient-provider communication and improves the patient experience. Clinical Relevance The visual explanation of PROMIS scores provided by this study may help new users of the PROMIS understand the instrument, feel empowered to incorporate it into their practices, and use it as a tool for counseling patients about their scores.
Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foram... more Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenos...
Study Design: Prospective cohort. Objectives: Patient-Reported Outcome Measurement Information Sy... more Study Design: Prospective cohort. Objectives: Patient-Reported Outcome Measurement Information System (PROMIS) has been validated for lumbar spine. Use of patient-reported outcome (PRO) measures can improve clinical decision making and health literacy at the point of care. Use of PROMIS, however, has been limited in part because clinicians and patients lack plain language understanding of the meaning of scores and it remains unclear how best to use them at the point of care. The purpose was to develop plain language descriptions to apply to PROMIS Physical Function (PF) and Pain Interference (PI) scores and to assess patient understanding and preferences in presentation of their individualized PRO information. Methods: Retrospective analysis of prospectively collected PROMIS PF v1.2 and PI v1.1 for patients presenting to a tertiary spine center for back/lower extremity complaints was performed. Patients with missing scores, standard error >0.32, and assessments with <4 or >...
Study Design: Retrospective cohort study. Objective: To determine the rates of perioperative comp... more Study Design: Retrospective cohort study. Objective: To determine the rates of perioperative complications in patients undergoing anterior cervical discectomy and fusion (ACDF) with allograft versus synthetic cage. Methods: A large national administrative health care database was queried for ACDF procedures performed between 2007 and 2014 using ICD-9 (International Statistical Classification of Diseases, 9th revision) and CPT (Current Procedural Terminology) codes. Cases that utilized structural allograft and synthetic cages were identified via CPT codes. Gender, age, frequency of obesity, cigarette use, diabetes, and number of levels fused were compared between the 2 cohorts using χ2 test. Complications within 90 days were identified via ICD-9 codes and compared between the 2 cohorts. Revision rates within 2 years were noted. Results: A total of 10 648 ACDF cases using synthetic cages and 7135 ACDFs using structural allograft were identified. The demographics between the 2 cohorts ...
Study Design: Systematic review. Objectives: To review, critically appraise, and synthesize evide... more Study Design: Systematic review. Objectives: To review, critically appraise, and synthesize evidence on the use of allogenic stem cell products for spine fusion compared with other bone graft materials. Methods: Systematic searches of PubMed/MEDLINE, through October 31, 2018 and of EMBASE and ClinicalTrials.gov through April 13, 2018 were conducted for literature comparing allogenic stem cell sources for fusion in the lumbar or cervical spine with other fusion methods. In the absence of comparative studies, case series of ≥10 patients were considered. Results: From 382 potentially relevant citations identified, 6 publications on lumbar fusion and 5 on cervical fusion met the inclusion criteria. For lumbar arthrodesis, mean Oswestry Disability Index (ODI), visual analogue scale (VAS) pain score, and fusion rates were similar for anterior lumbar interbody fusion (ALIF) using allogenic multipotent adult progenitor cells (Map3) versus recombinant human bone morphogenetic protein–2 (rhBM...
Objective Visual cohort analysis utilizing electronic health record data has become an important ... more Objective Visual cohort analysis utilizing electronic health record data has become an important tool in clinical assessment of patient outcomes. In this article, we introduce Composer, a visual analysis tool for orthopedic surgeons to compare changes in physical functions of a patient cohort following various spinal procedures. The goal of our project is to help researchers analyze outcomes of procedures and facilitate informed decision-making about treatment options between patient and clinician. Methods In collaboration with orthopedic surgeons and researchers, we defined domain-specific user requirements to inform the design. We developed the tool in an iterative process with our collaborators to develop and refine functionality. With Composer, analysts can dynamically define a patient cohort using demographic information, clinical parameters, and events in patient medical histories and then analyze patient-reported outcome scores for the cohort over time, as well as compare it ...
Objectives. To examine the relationship between the Patient Reported Outcome Measurement Informat... more Objectives. To examine the relationship between the Patient Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and PROMIS Physical Function (PF) scales in patients with spinal pain at a university spine center. Design. Retrospective analysis of prospectively collected patient-reported outcome data at a university spine clinic. Pearson correlation was done to examine the relationship of the PROMIS PF and PROMIS PI scores. Age, gender, and race were analyzed by subgroups on the PROMIS Physical Function and Pain Interference score. Linear regression analyzed predictive relationships. Statistical significance was set at P < 0.05. Results. A total of 1,992 participants completed an assessment, with 1,923 completing the PF CAT and 1,927 the PI CAT. Participants' mean age was 52.8 years (range 5 18-94 years, SD 5 6.5 years). Correlation analysis of the PROMIS PF with the PROMIS PI showed a Pearson correlation value of-0.717 (P < 0.05). There was a strong linear relationship with a high negative correlation between PF CAT and PI CAT. The PI CAT predicted PF CAT scores (b 5-0.707, P < 0.001). Conclusions. For patients with pain from spinal origin, there is a strong negative correlation between self-reported physical function and pain interference related to physical, social, and mental health. The predictive relationship of function from pain scores supports the PROMIS PI being used as an important adjunct measure of physical function in patients with spinal pain.
Background Context-The Patient-Reported Outcomes Information System (PROMIS) instruments are an i... more Background Context-The Patient-Reported Outcomes Information System (PROMIS) instruments are an important advancement in the use of PROs, but need to be evaluated with longitudinal data to determine whether they are responsive to change in specific clinical populations.
Journal of the American Board of Family Medicine : JABFM
Physical therapy (PT) early in the management of low back pain (LBP) is associated with reduction... more Physical therapy (PT) early in the management of low back pain (LBP) is associated with reductions in subsequent health care utilization and LBP-related costs. The objectives of this study were to 1) Examine differences among newly consulting patients with LBP who received a PT referral and those who did not, 2) examine differences between patients who participated in PT to those who did not, and 3) compare the impact of a PT referral and PT participation on LBP-related health care utilization and costs over 1 year. This was a retrospective cohort study using electronic medical records and claims data. Participants were 454 Medicaid enrollees with new LBP consultations (mean age, 40.4 years; SD = 12.0; 70% women). Outcomes included advanced imaging, injections, emergency department visits, opioid prescriptions, surgery and LBP-related costs. Variables associated with a PT consult, PT participation, and subsequent outcomes were evaluated with multivariate models. A total of 251 (55%)...
Patient-reported outcomes (PROs) have traditionally been implemented through a manual process of ... more Patient-reported outcomes (PROs) have traditionally been implemented through a manual process of paper and pencil with little standardization throughout a Healthcare System. Each practice has asked patients specific questions to understand the patient's health as it pertains to their specialty. These data were rarely shared and there has not been a comparison of patient's health across different specialty domains. We sought to leverage interoperable electronic systems to provide a standardization of PRO assessments across sites of care. University of Utah Health is comprised of four hospitals, 12 community clinics, over 400,000 unique annual patients, and more than 5000 providers. The enterprise wide implementation of PROs started in November of 2015. Patients can complete an assessment at home via email, or within the clinic on a tablet. Each specialty has the opportunity to add additional specialty-specific instruments. We customized the interval with which the patient ans...
Computer methods in biomechanics and biomedical engineering, Jan 16, 2018
Finite element analysis has proven to be a viable method for assessing many structure-function re... more Finite element analysis has proven to be a viable method for assessing many structure-function relationships in the human lumbar spine. Several validated models of the spine have been published, but they typically rely on commercial packages and are difficult to share between labs. The goal of this study is to present the development of the first open-access models of the human lumbar spine in FEBio. This modeling framework currently targets three deficient areas in the field of lumbar spine modeling: 1) open-access models, 2) accessibility for multiple meshing schemes, and 3) options to include advanced hyperelastic and biphasic constitutive models.
Systematic review. The aim was to determine the fusion efficacy of allograft and demineralized bo... more Systematic review. The aim was to determine the fusion efficacy of allograft and demineralized bone matrix (DBM) in lumbar instrumented and noninstrumented fusion procedures for degenerative lumbar disorders. A literature search was conducted using the PubMed and Cochrane databases. To be considered, publications had to meet 4 criteria: patients were treated for a degenerative lumbar disorder, a minimum group size of 10 patients, use of allograft or DBM, and at least a 2-year follow-up. Data on the study population, follow-up time, surgery type, grafting material, fusion rates, and its definition were collected. The search yielded 692 citations with 17 studies meeting the criteria including 4 retrospective and 13 prospective studies. Six studies used DBM and 11 employed allograft alone or in the combination with autograft. For the allograft, fusion rates ranged from 58% to 68% for noninstrumented and from 68% to 98% for instrumented procedures. For DBM, fusion rates were 83% for non...
The spine journal : official journal of the North American Spine Society, Jan 18, 2017
Several studies have suggested that lab results have minimal impact on clinical decision-making i... more Several studies have suggested that lab results have minimal impact on clinical decision-making in surgery. Despite the widespread use of preoperative testing in spine surgery and the large volume of posterolateral lumbar fusions (PLFs) being performed each year, no study has assessed the ability of preoperative labs to predict adverse events following PLF. The purpose of this study was to explore the relationship between commonly obtained preoperative lab results and postoperative complications following 1-2 level PLF. This is a retrospective study of prospectively collected data. The 2006-2013 ACS-NSQIP database was employed to identify all patients who underwent 1-2 level PLF. The outcome variables of interest were 30-day postoperative complications, which were assessed as major complications, minor adverse events, and total complications. Demographics, comorbidities, and perioperative characteristics were collected for each patient. Preoperative labs included sodium, BUN, creati...
Study Design: Retrospective case study. Objective: To evaluate the trends and demographics of rec... more Study Design: Retrospective case study. Objective: To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States. Methods: Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient. Results: A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence...
Commonly used exposures in spinal surgery procedures do not allow the surgeon to visualize the po... more Commonly used exposures in spinal surgery procedures do not allow the surgeon to visualize the position of instrumentation in relation to important deep bone, vascular, and neurological structures. This hidden anatomy can be violated in the operative suite without the surgeon's knowledge, causing irreversible harm to patients or jeopardizing fixation of instrumentation. Current intraoperative imaging devices expose both patient and surgeon to harmful radiation. Advances in imaging technology, computers, and operative technique allow the surgeon to visualize hidden anatomy. Several new modalities including computed tomography (CT) and magnetic resonance imaging (MR[) guidance systems, ~nultidimensional intraoperative fluoroscopy, intraoperative Fluoro/CT scanning, and intraoperative magnetic resonance imaging have become available to assist surgeons. Image guided spinal surgery may reduce risks to patients and surgeons while allowing for more accurate instrumentation and resection in complex spinal procedures.
Study Design: Systematic review. Objectives: The primary objective of this systematic review was ... more Study Design: Systematic review. Objectives: The primary objective of this systematic review was to define the change in impairment, disability, and pain following surgical intervention in patients with degenerative cervical myelopathy (DCM). Secondary objectives included to assess the impact of preoperative disease severity and duration of symptoms on outcomes and to summarize complications associated with surgery. Methods: A systematic literature search was conducted to identify prospective studies evaluating the effectiveness and safety of operative treatment in patients with DCM. Outcomes of interest were functional status, disability, pain, and complications. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and the strength of the overall body of evidence was rated using guidelines outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. Results: Of the 385 retrieved citations, 32 met inclusion criteria and...
Objective: To develop recommendations on the timing of surgical decompression in patients with tr... more Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at...
Objectives: After the Food and Drug Administration approved bone morphogenetic protein-2 (BMP) in... more Objectives: After the Food and Drug Administration approved bone morphogenetic protein-2 (BMP) in 2002, BMP was used off-label in the cervical spine to increase bone growth and bony fusion. Since then, concerns have been raised regarding complication rates and safety. This study was conducted to examine the use of BMP in anterior cervical discectomy and fusion (ACDF) in the Medicare population and to determine risk of complications and associated costs within 90 days of surgery. Methods: Patients who underwent ACDF were identified using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision Procedure codes (ICD9-P). Complications were identified using ICD9 diagnostic codes. Charges were calculated as amount billed, and reimbursements were calculated as amounts paid by Medicare. Data for these analyses came from a nationwide claims database. Results: A total of 215 047 patients were identified who had ACDF from 2005 to 2011. For the majority of the procedures (89.0%), BMP was not used. BMP use rose from 11.84% in 2005 to a peak of 16.73% in 2007 before decreasing to 12.01% in 2011. BMP was used 16% more in women than men. BMP use was the highest in the West (13.6%) followed by Midwest (11.8%), South (10.6%), and Northeast (7.5%). There was a higher overall complication rate in the BMP group (2.1%) compared with the non-BMP group (1.9%) (odds ratio [OR] ¼ 1.11, 95% CI ¼ 1.01-1.22). The BMP group also had a higher rate of wound complications (0.98% vs 0.76%, OR ¼ 1.29, 95% CI ¼ 1.12-1.48). In this study population, there was no difference in dysphagia/hoarseness, neurologic, medical, or other complications. During the 90-day perioperative period, BMP surgeries were charged at 17.6% higher than non-BMP surgeries. Conclusions: The use of BMP in ACDF in the Medicare population has decreased since a peak in 2007. The rate of wound and overall complications for BMP use with ACDF was higher than without. Our results regarding dysphagia/hoarseness did not show a statistically meaningful difference, which is in contrast with many other studies. Charges associated with BMP use were higher during the 90-day perioperative period.
Patient-reported outcome measures PROMs are the most widely accepted means of measuring outcomes ... more Patient-reported outcome measures PROMs are the most widely accepted means of measuring outcomes following spine procedures. We sought to determine the current status of worldwide use of PROMs in Latin America (LA), Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) in order to determine the barrier to its full implementation. A questionnaire survey was sent by e-mail to members of AOSpine to evaluate their familiarity and use of PROMs instruments, and to assess the barriers to their use in spine care practice in LA, EU, AP, NA, and ME. A total of 1,634 AOSpine members from LA, EU, AP, NA, and ME answered the electronic questionnaire. The percentage of spine surgeons familiar with the generic health-related quality of life (HRQoL) questionnaire was 71.7%. in addition, 31.9% of respondents did not routinely use any PROMs. The main barriers to implementing PROMs were lack of time to administer the questionnaires (57%) followed by lack of staff to assist in data collection (55%), and the long time to fill out the questionnaires (46%). The routine use of questionnaires was more frequent in NA and EU and less common in LA and ME (p&amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). We found that 31.9% of spine surgeons do not routinely use the PROMs questionnaire. This appears to occur because of lack of knowledge regarding their importance, absence of reimbursement for this extra work, minimal financial support for clinical research, the cost of implementation and lack of concern among physicians.
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Papers by Darrel Brodke