Experts in Action
By Elaine Porterfield
A Group Health team is gaining national attention with a new approach and improved results for complex spinal surgery.
The patient, Ali, an active and fit woman, was in her late 20s when she was diagnosed with a large tumor. It was growing from her spine into her pelvis and involved various nerves. Removing it would be difficult: If something went wrong, she could lose critical nerve function resulting in muscle weakness, partial paralysis, or loss of bowel and bladder function.
Leaving the tumor alone wasn't an option. It would continue growing and eventually damage pelvic organs, and it could develop into a cancer and spread. But removing it required freeing it from major abdominal blood vessels that carry blood from the heart to the legs, and moving bowel and reproductive organs out of harm's way. The most delicate part of the procedure would be separating the tumor from the nerve roots that exited near the sacrum — the bone at the base of the spine — and from the lower part of the spine.
Fortunately for Ali, this type of complex spine surgery — involving a spinal deformity, spinal tumor, or requiring a major reconstruction — is the focus of a Group Health medical team that has been attracting regional and national attention. Some cases the group takes on require up to five attending surgeons representing multiple surgical subspecialties, including neurosurgery, orthopedic surgery, general surgery, vascular surgery, orthopedic oncology, and thoracic surgery. The team of more than 20 individuals also includes specialists in anesthesia and physiatry, as well as specially trained nurses, physician assistants, and physical therapists.
It's a team so good that its members are being invited to speak around the country about their unique approach which has resulted in a three-fold decrease in the complications that can follow these complex surgeries.
This success has led to a special collaboration with Virginia Mason (VM). Through a long-standing agreement, Group Health patients have for some time been able to receive hospital care at Virginia Mason from Group Health doctors. But the hospital — regarded as one of the best in the nation — recently invited the Group Health spinal surgery team to also perform complex spine surgeries on other Virginia Mason patients. Group Health and Virginia Mason surgeons often work side by side during the surgeries, though most surgeons are with Group Health.
"Virginia Mason is delighted to work with Group Health's spine surgery team," says Michael Glenn, MD, physician-in-chief at Virginia Mason. "Their physicians have a clear commitment to quality care and demonstrate consistently outstanding outcomes for spine surgeries."
Teleconferencing Extends Expertise to Primary Care Statewide
These Group Health spinal surgeons are extending their reach far beyond the operating room at VM in Seattle. Increasingly, Group Health primary care physicians throughout the state are consulting with them on spinal cases via teleconferencing and shared digital imaging.
Marc Mora, MD, medical director of specialty care for Group Health, provides this example: "The spinal team doctors can say, based on what I'm seeing, I don't think your patient needs an operation or does need an operation. This allows our 400 primary care physicians and their patients to take advantage of this renowned team's advice without initial travel and inconvenience for the patient."
Spinal surgery specialists with Group Health are also able to benefit from something that's hard to come by in other medical practices, says Rajiv Sethi, MD —the chance to focus on patient care from start to finish, without worrying about also running a private practice like so many physicians must do. It's what attracted him to Group Health, says Dr. Sethi, the leader of the neurosurgery team and a Harvard-trained physician with advanced training in orthopedics.
"I can make decisions here based on medical need, not financial decisions," says Dr. Sethi. "I can just be a surgeon and a doctor. It's a more rational and reasonable way to think about complex spinal cases."
Better Results for Patients
Out of dozens of operations Dr. Sethi's team performs each month, about 10 are complex spinal surgeries. Patients, who range from age 16 to 85, can be suffering from conditions that include tumors, nerve injuries, spinal deformities, major curvatures, and other assorted conditions and injuries.
Each of these operations starts with a monthly case conference — attended by both Group Health and Virginia Mason surgeons — where the team makes decisions about which patients should have surgery. Everyone involved in the care of potential spine surgery patients — as many as two dozen clinicians— comes together to review patient treatment plans.
"They talk about a patient's age, surgical history, medical problems, and what we might anticipate in a patient's surgery and recovery," Dr. Mora says. "Everyone makes an assessment and recommendation. It gives patients the full benefit of all the expertise of these specialists, and of the risks and benefits of surgery. When a patient comes to the hospital, everyone on the team knows all about the patient, what to expect, and how we're going to prevent any medical complications."
Neurosurgeon Jean-Christopher Leveque, MD, is a team member who is often in the OR with Dr. Sethi. The two have worked together for years, pioneering a dual surgeon approach to complex spine surgery. It is this approach — which combines their two areas of surgical expertise, neurosurgery and orthopedics — that has led to the significant reduction of complication rates in these complex surgeries.
Having two surgeons working in tandem reduces the time the patient spends in surgery and the chance that an error will occur. "We also save time and waste by using one another's eyes and minds to check our work," says Dr. Leveque. Early collaboration with anesthesia also makes a difference, he says. "At most institutions, surgeon and anesthesiologist first discuss a case 10 minutes before the case begins. With our preoperative conference and in-depth discussion, we've taken every opportunity to ferret out issues and minimize the chance of anyone being surprised during surgery."
For patients, the surgery can initially sound overwhelming, which is why Joan Poochoon, RN, clinical operation manager at Group Health's Capitol Hill Campus, helped develop a class to educate patients and their caregivers about what to expect before, during, and after procedures. "We start from when patients come in to see physicians to when nurses take over, to make sure we have all of the logistics covered," she says.
As for Ali, the young woman with the pelvic floor tumor, her outcome was terrific. Five-and-a-half weeks after her surgery, she gives this report: "I am walking without weakness. The tumor was benign, and I feel like I've overcome a huge obstacle. I cannot put into words how lucky and appreciative I feel about getting to work with these excellent surgeons.
"Thank you for giving me the best care possible. For a while I was scared for my life, but I was walked through each step of the process carefully and thoughtfully by this group of doctors. I truly feel like they saved my life."
Research Confirms Reduction in Complications
In 2010, the Group Health Foundation awarded Rajiv Sethi, MD, a Partnership for Innovation grant to measure the effectiveness of the dual surgeon approach to complex spinal surgeries in reducing complications and improving patient outcomes. Results confirm that this approach is accomplishing both of those things. Results of new complex spine cases continue to be entered into a database maintained by Dr. Sethi and investigators at the Group Health Research Institute. This allows for ongoing modifications to the team approach.
Dr. Sethi has been invited to speak about this approach at major national and international meetings of surgeons. Recently, one of his research papers was rated among the top 10 out of more than 1,100 presented at an international neurosurgery conference. He has also given grand rounds on the Group Health approach to complex spinal surgery at several institutions, and is presenting a paper in July that is nominated for the prestigious Whitecloud Clinical Research Award by the Scoliosis Research Society.