title: Changes in the care of patients with cervical spine fractures following health reform in Massachusetts.
abstract: BACKGROUND
  There is a substantial concern among spine surgeons that healthcare reform efforts will alter the processes through which spinal care is delivered and decrease overall quality. We used the Statewide Inpatient Dataset for Massachusetts to evaluate changes in hospital processes and quality of care for patients with cervical fractures following the implementation of health reform.
  
  
  METHODS
  This was a pre-post retrospective analysis of patients (n=9,387) treated for cervical fractures in Massachusetts between 2003-2006 and 2008-2010. Changes in hospital processes (surgical intervention, length of stay (LOS) and environment of care) and quality of care (mortality, complications, reoperation and failure to rescue (FTR)) were the outcomes of interest. FTR is a quality measure that evaluates a hospital's capacity to avoid mortality following the occurrence of a sentinel complication. Patients treated between 2003 and 2006 were considered the pre-reform group. The post-reform cohort consisted of those treated from 2008 to 2010. Baseline differences between cohorts were evaluated using chi-square or Mann-Whitney U tests. Unadjusted comparisons between the dependent variables and the onset of healthcare reform were performed, followed by regression techniques that adjusted for differences in case-mix and whether a surgical intervention was performed. Multivariable logistic regression was used for categorical variables and negative binomial regression was employed for continuous variables.
  
  
  RESULTS
  The rates of surgical intervention remained unchanged pre- and post-reform (p=0.25). Hospital length of stay (RC: -0.18, 95% CI: -0.22, -0.14) and the FTR rate following surveillance insensitive complications (OR: 0.49, 95% CI: 0.25, 0.94) were significantly reduced following health reform. Post-reform, academic centers experienced a 22% reduction in mortality (95% CI: 0.61, 0.99) a 40% decrease in FTR (95% CI: 0.40, 0.89), a 30% decrease in surveillance insensitive complications (95% CI: 0.51, 0.96) and a 67% reduction in FTR after surveillance insensitive morbidity (95% CI: 0.11, 0.94).
  
  
  CONCLUSIONS
  In the period following Massachusetts healthcare reform, significant improvements were noted in hospital process and quality measures around the care of patients with cervical spine fractures. Such findings were particularly robust among academic centers. These results may forecast changes in the delivery of spine surgical care following other health reform initiatives. Level of Evidence III.
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Electronic address: ajschoen@neomed.edu.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Schoenfeld
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48104, USA.
authors.forename: Trevor C
authors.initials: TC
authors.lastname: Wahlquist
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Bono
authors.affiliation: Center for Healthcare Outcome and Policy, University of Michigan, Ann Arbor, MI 48109, USA.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Lehrich
authors.affiliation: Robert Wood Johnson Clinical Scholars Program, Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
authors.forename: Robyn K
authors.initials: RK
authors.lastname: Power
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
authors.forename: Mitchel B
authors.initials: MB
authors.lastname: Harris
mesh_terms: D002574:Cervical Vertebrae / Q000293:injuries*; D005260:Female; D018166:Health Care Reform; D054625:Healthcare Disparities / Q000191:economics / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D011183:Postoperative Complications / Q000191:economics / Q000401:mortality*; D012086:Reoperation; D012151:Resuscitation / Q000191:economics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016103:Spinal Fractures / Q000401:mortality / Q000601:surgery*; D015996:Survival Rate
keywords: Academic medical centers; Cervical spine fractures; Failure to rescue; Health reform; Mortality; Quality improvement