Robert E. Harbaugh, MD, FAANS, NeuroPoint Alliance Chair, will be presented with the Distinguished Service Award during the 2018 AANS Annual Scientific Meeting. He is a very appropriate choice, given the meeting theme: The Privilege of Service.
NeuroPoint Alliance (NPA) is one of the many initiatives led by Dr. Harbaugh that will have a long-term impact on the specialty of neurosurgery and was a major factor that contributed to this award . In this light, we asked Dr. Harbaugh to discuss the origins and evlolution of NPA.
While I was at Dartmouth in the late 80s and early 90s, a group of surgeons there formed the Dartmouth Surgical Outcomes Committee. This group of physicians came together, united in the belief that the way to improve surgical care is to track patient characteristics, processes of care and patient outcomes, analyze the data and feed it back to individual surgeons in a non-punitive environment. Each one of those doctors has gone on to continue that work, establishing national outcomes assessment databases in various specialties. This is the “Science of Practice” – the habitual and systematic collection of data, inseparable from practice, via audited registries. Analysis of this data generates new knowledge about the effectiveness of care and operative indications and application of that knowledge improves the quality of care. Helping to establish a neurosurgical culture of quality improvement through outcomes assessment has been a contribution to our specialty of which I am proud.
The first national, neurosurgical quality improvement effort was the AANS/CNS Committee for the Assessment of Quality (CAQ), chaired by Robert E. Florin, MD, FAANS(L). That committee had three subcommittees: Guidelines, Outcomes and Practice Assessment. I chaired the Outcomes subcommittee until the CAQ was disbanded, leaving organized neurosurgery with no ongoing outcomes assessment quality improvement effort.
To counter this, the AANS started the Neuro Knowledge program in 2001. This program was a joint effort between the AANS and Outcome Science, a data collection organization. I chaired the advisory committee for this program. We developed password-protected, secure databases for lumbar discectomy, ventriculoperitoneal shunts, surgery for subdural hematomas and carotid endarterectomy. These could be accessed online and were free for AANS members to use. They were almost entirely ignored by neurosurgeons. Very few people in our specialty had any interest in outcomes assessment as a means to quality improvement at that time.
When Jon H. Robertson, MD, FAANS, was president of the AANS, he and I approached Douglas S. Kondziolka, MD, FAANS, then president of the CNS, about forming an alliance among the AANS, CNS and the American Board of Neurological Surgery (ABNS) to develop an outcomes assessment platform that could be used for quality improvement, clinical research, maintenance of certification and other projects. From this conversation, the early plans for what would become the NPA were developed. Although the CNS and the ABNS eventually chose not to become partners in the NPA, they both agreed to give the new organization their support.
So, the NPA became an alliance of one: the AANS. Once it was clear we were going it alone, things moved more quickly, and in 2008, the NPA was incorporated as a 501(c)(6) organization, governed by a Board of Directors with voting representatives from the AANS, the CNS, the Society of Neurological Surgeons, the ABNS and the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves. The Board also includes the Editor-in Chief of the Journal of Neurosurgery (JNS) and the Chair of the Neurosurgery Research & Education Foundation (NREF) as ex-officio members.
The NPA, Inc. had become a true neurosurgical alliance. Paul C. McCormick, MD, FAANS, while serving as AANS president-elect, advocated for the AANS to use reserve funds to get the organization going, and Anthony L. Asher, MD, FAANS recognized that there were now practices who would pay to be involved in outcomes assessment for quality improvement and business purposes. After performing several small, proof-of-concept outcomes studies, the National Neurosurgical Quality Outcomes Database (N2QOD) was started and supported by annual subscription fees from the users.
N2QOD achieved great success, with more than 80,000 patients enrolled. Starting with spine surgery procedures, the menu has expanded to include neurovascular procedures and a tumor module will soon be added to the options. Despite the strong brand built with N2QOD, 18 months ago NPA changed the name to Quality Outcomes Database (QOD). This was necessary as the registries are collecting data from specialists other than neurosurgeons, and it is anticipated that the partnerships outside of neurosurgery will continue to expand.
At the moment, the NPA is evaluating ways to manage its growth, to choose the right partners and to put the NPA on a solid business footing for the future. We are spending more time and energy marketing to hospitals and health systems to take some of the financial burden for NPA off of individual practices. We also are talking to the Food and Drug Administration (FDA) and our industry partners to see how the NPA can use its infrastructure and expertise for pre-marketing evaluation and post-marketing surveillance of neurosurgical devices. We are working with the U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) on its Registry of Patient Registries project to see if we can harmonize multiple existing registries for evaluating the treatment of patients with degenerative spondylolisthesis. This year we also will hold our first NPA course. This course, entitled The NeuroPoint Alliance, Inc. (NPA) and Your Practice: Using Registries to Enhance Quality, Reimbursement, Certification and Clinical Research, will be held on Sunday April 29, 2018, from 7:30 a.m.- 4:30 p.m. in New Orleans immediately prior to the 2018 AANS Annual Scientific Meeting.
NPA has several very exciting cooperative projects in progress and development. The Stereotactic Radiosurgery Registry (SRS), generously supported by Brainlab, brings together neurosurgery and radiation oncologists to improve outcomes and support informed decision making in radiosurgery. This registry has now enrolled almost 3,000 patients. We are also working with the Society of NeuroInterventional Surgery (SNIS) to merge our respective neurovascular registries to create a single platform that will capture neurovascular procedures done by neurosurgeons, endovascular neurologists and interventional neuroradiologists. This collaboration is of particular relevance to the FDA as a way to assess new and previously approved devices.
The Registry for the Advancement of DBS Therapy in Parkinson’s Disease (RAD-PD) registry, which is being supported by the Michael J. Fox Foundation, is bringing together functional neurosurgeons and movement disorder neurologists. This joint registry effort will launch later this year. We are working with the Hydrocephalus Research Network to develop a quality improvement program for the treatment of pediatric hydrocephalus that will be used in children’s hospitals all across the country. Finally, we are working with the ABNS to apply our expertise in data collection, analysis and feedback to improve the board and maintenance of certification processes.
NPA has reached what I think of as its ‘organizational adolescence.’ It is poised to do important things for neurosurgery over the next 10 years if we can continue to garner the support of organized neurosurgery. The Science of Practice approach is the best documented process for improving quality of care in surgical disciplines. This approach will help to improve patient outcomes, reduce length of stay and decrease readmissions. Patient care that is safer and more efficient will greatly increase the value of neurosurgical treatment. The Science of Practice is more challenging for neurosurgery than for many specialties because of the wide range of procedures we offer for many different disease processes. I am very proud of our specialty for accepting the challenge and responding in such a valuable fashion.
Dr. Harbaugh is the University Distinguished Professor and Chair of the Department of Neurosurgery and the Director of the Neuroscience Institute at Penn State. In 2013, he was named a Penn State Alumni Fellow, the highest award of the Penn State Alumni Association. He also holds a clinical appointment as guiding professor of neurosurgery at Huanhu Hospital in Tianjin, China.
Dr. Harbaugh has been an invited speaker throughout the world. His research interests include clinical trial design, outcomes analysis, quality improvement in neurosurgery and neural engineering. He has edited three books and published more than 400 articles, book chapters and abstracts on various neurosurgical topics. Dr Harbaugh also has served on the editorial boards of Neurosurgery, the AANS Neurosurgeon, the Journal of Neurovascular Disease, the Journal of Neuropsychiatry and Clinical Neurosciences and Neurobiology of Aging.
Dr. Harbaugh has obtained research funding from the NIH, NATO, USDA, the Commonwealth of Pennsylvania, industry, foundations and other organizations. He is a member of the American Board of Neurological Surgery (ABNS), the Society of Neurological Surgeons (SNS), the American Academy of Neurological Surgery (AANS), the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the AANS/CNS Cerebrovascular Section (CVS), the AANS/CNS Tumor Section, the American Stroke Association (ASA), the American Heart Association (AHA) Stroke Council, the New England Neurosurgical Society (NENS), the Pennsylvania Neurosurgical Society (PNS) and the American College of Surgeons (ACS).
Dr. Harbaugh has held numerous leadership positions in these organizations, including Chair of the CV Section, Chair of the AANS/CNS Washington Committee, President of the NENS, Vice-President of the Academy, Director of the ABNS, SNS President and AANS President. He presently serves as Chair of the Board of Directors of the NeuroPoint Alliance, Inc., as a member of the Accreditation Council for Graduate Medical Education’s Residency Review Committee for Neurosurgery, as a member of the Steering Committee of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, as Co-Chair of the Agency for Healthcare Research and Quality’s Registry of Patient Registries project and as a member of the Governance Council for the Food and Drug Administration’s coordinated registry network for Devices used for Acute Ischemic Stroke Intervention (DAISI) project.
Dr. Harbaugh also served as a member of the National Football League’s Head, Neck and Spine Committee and its Injury Surveillance Committee, as a member of the Strategic Vision Committee of the Federal Interagency Traumatic Brain Injury Registry (FITBIR), the Board of Trustees of the Penn State Hershey Medical Center, Lebanon Valley College and the Saint Joan of Arc School.