Closing the loop between evidence-based medicine and care delivery: a possible role for clinical audits in spinal surgery

Background context: Evidence-based medicine (EBM) should be the ultimate force driving change in clinical practice. This process generally occurs through a trickle-down phenomenon by which practice recommendations are revised, modified, and/or changed based on the best published data. Recommendations are subsequently incorporated by individual physicians. The fundamental assumption that drives this paradigm is that adopting evidence-based recommendations and/or treatment guidelines will result in improved outcomes. Unfortunately, to date, the paradigm does not have an effective feedback loop that would then evaluate whether the changes did, in fact, improve outcomes.

Purpose: To explore the process of clinical audits as a mechanism by which to provide a feedback loop to evaluate the results of spinal surgery on an individual basis and whether those results can be improved.

Study design: Review article, discussion.

Methods: A literature review of the current data regarding clinical audits was performed, and a discussion of how they may apply to spinal surgery is offered.

Results: Clinical audits have been used outside the United States, particularly in the United Kingdom, to fulfill this function. A clinical audit would allow a practicing spinal surgeon to examine his or her individual experience and determine if it is achieving the expected outcome based on published results. In the most important feature of a clinical audit, the reaudit, if an individual's results are found to be inconsistent with published results, it presents an opportunity to identify if there are reconcilable differences from which potential improvements can be made. Effectively, this "closes the loop" between EBM and actual clinical practice.

Conclusions: Documenting improved outcomes through the audit process can impact spinal care in several ways. Patients would receive a clear message that their doctors are interested in improving care. Hospitals will use the information to optimize treatment algorithms. Finally, insurers might make the audit process more tenable or attractive by indicating a physician's voluntary participation as a criterion to be a preferred provider.