NASS 2024 RECAP
Dr. Ghogawala’s Speech Highlights Presidential Symposium
Jason Friedrich, MD
SpineLine Deputy Editor University of Colorado Hospital Spine Center Denver, CO
Nothing could set the stage better for a discussion about the future of spine care than a genuine and inspiring Presidential speech by Dr. Zoher Ghogawala on the delicate balance between empathy and efficiency.
With a heartfelt tone, he explained how empathy can guide us to a sense of purpose, better evidence, and better outcomes. He explained how adopting technological advances in the name of efficiency only may misguide us to do the wrong things faster. An empathetic approach to adopting new technology that emphasizes patient welfare over efficiency will improve our connection to patients. Improved connection to our patients and our peers feeds our purpose, reduces burnout and can elevate the health of our patients. He stated that “empathy means evidence,” which served as a segue to an impressive panel of spine and health care experts.
In Dr. Ghogawala’s words, “This symposium will bring together leaders in health care and spine to present current resources and programs available to address these challenges, as well as ongoing efforts to collaborate for a shared vision for the future that embraces emerging technologies and innovation for an ever-evolving health care system.”
Participants
The panel nicely complemented Dr. Ghogawala’s message on empathy as a guiding principle for spine health care, research and innovation. Dr. Cook, Executive Director of PCORI, which is a leading funder of comparative research in the US, discussed a focus on “patient engagement” in spine research, with outcomes designed with the direct input of the patients being studied. This concept mirrors the shared decision-making conversations tantamount to patient-physician encounters.
Dr. Washabaugh (NIH, NIAMS) emphasized the importance of collaboration in spine research, training the next generation of clinician-scientists, and identification of biomarkers for determining which patients are most likely to respond to particular treatments for spine conditions. Dr. Shaffrey (Duke) echoed the importance of biomarker research in spine care to implement personalized graduated care pathways for patients. Efficiency modeling may tell us to push patients through the system faster in order to identify elective surgical candidates. This misses the mark for many patients, exposes others to undue burden or harm, and fails to elevate community spine health overall.
Dr. Kreiner, NASS’ new President, explained that the principles of differentiation in spine patients is equally critical in the nonoperative spine population. To use Dr. Shaffrey’s example, if we take a truly empathetic approach when thinking about spine care in the elderly community, then bone health, sarcopenia, and social determinates of health will quickly rise to the top of our priority list to focus on for new spine research and health initiatives.
Dr. Roy and colleagues at the National Spine Health Foundation have already been applying this approach through responsibly messaging important information about spine care to patients and their families through spinehealth.org. I encourage everyone to review their “Osteoporosis and the Spine” pages and infographics found at https://spinehealth.org/article/osteoporosis/, and share with your patients.
Shifting gears, Dr. Patel (Northwestern) nicely articulated the natural tension between population averages and individual patient goals. His comments echoed Dr. Ghogawala’s message that “empathy is hard and takes persistence.” As an example, Dr. Ghogawala provided a case presentation of two brothers each with a grade 1 degenerative spondylolisthesis but very different treatment goals. To understand a patient’s individual goals takes time. Individual treatment goals greatly affect clinical decision-making, but are not always reflected in clinical research studies or guidelines.
The conversation then shifted to new technology in spine care. Dr. Wang (Miami, ISASS President) and Dr. Hu (Stanford) reflected on the amazing technological growth in spine care followed by a humble reality check: What good is all the technology if we do not know when to apply it or recognize its limits?
Dr. Fleisher (CMS) took this concern a step further and explained the frequent gap between FDA approval for new technology and proven benefit in a sample representative of the Medicare population. He would like to see more real-time outcomes data dashboards to enhance payor decision-making. He also hopes to find opportunities to create payment bundles starting at symptoms or diagnosis, rather than only anchored to the surgery. This makes sense when considering comments from Dr. Polly (Minnesota) and others reminding us that non-operative care, especially for spine deformity patients, carries recurring costs and patient burden.
Conclusion
Surprisingly, insurance preauthorization rules were not specifically addressed in this symposium. Reflecting on what several panel members said regarding need for more consistent diagnostic labeling, more phenotyping or subgrouping of spine patients to allow more individualization of treatment plans, there does appear to have been a large elephant in the room (called insurance preauthorization rules) that can serve to force some patients to occasionally endure irrelevant nonoperative care before being considered for more individualized surgical treatment.
In summary, while Dr. Ghogawala’s philosophy of care was very inspiring and the panel thought leaders listed many opportunities to improve the field, there are naturally many covariables impacting effective change. These include aging population, social determinates of health, potential for over-reliance on technology for care delivery (including surgery), and significant friction in the system for patients to access care and for physicians to deliver optimal care.
Even patients who have adequate insurance for care still face many obstacles for spine care: scheduling hurdles, billing or authorization confusion, geography (especially rural patients), and treatment variability even when the diagnosis is clear. Dr. Curry (CMO, Mass General) and others gave social determinates of health the most attention as a barrier to achieving optimal outcomes. Dr. Cook (PCORI) reported that 80% of our treatment outcomes can be attributed to social determinates of health (eg, economics, education, housing, health care access, etc), while our clinical decision-making and surgical skill account for the remaining 20%. Efficiency and volume tactics, such as room utilization metrics, will not solve this.
In the end, the highlight of the session was outgoing NASS President Dr. Ghogawala’s authenticity, which should inspire all of us to act with more empathy. The rest of the session provided a list of opportunities or topics of focus, but not necessarily tangible solutions or next steps. Perhaps the best solution right now is to let empathy guide more of our decisions and keep bringing people together.