Excellence is defined as a state of being “superior; imminently good.”  To be excellent, one must show how they are better than another.  In general, this requires some system of measurement.  Measuring outcomes is commonplace in everyday life. For example, the avid golfer uses the handicap score to measure one’s skill relative to another.  Similarly, baseball uses the ERA (earned run average) to compare pitching effectiveness.  Thus, excellent golfers and baseball pitchers would simply be those players who have the best scores.  It is only logical that excellent surgeons would be identified as those having the best treatment scores.

Unfortunately, the human condition is far more complex than golf or baseball.  The diversity of human disease and its clinical manifestations is vast.  The task of organizing disease states and measuring treatment outcomes can be overwhelming. But, it is not impossible.  The variability and complexity of spinal disorders can be addressed by gathering information in sufficiently large numbers such that patients can be grouped into “buckets”.  This can be readily accomplished if a large number of surgeons participate in an outcomes registry.  Therein lies the rub.  In our efforts to collect meaningful data, we have burdened ourselves with a task that is not compatible with everyday practice.  We often fall into the trap of attempting to gather information far above that which is required for the everyday care of our patients.  Today, most surgeons are too busy to withstand that incremental burden on their clinical practice.  Ultimately, this leads to poor surgeon participation and low enrollment.  To successfully develop a large outcomes registry, the data collection requirements must be minimized.

As in most things, timing is everything. The field of spine surgery currently enjoys an unprecedented degree of agreement on one issue:  clinical outcomes measures.  It is now expected that clinical studies report the Visual Analog Scale (VAS) for pain, a system-specific functional outcomes score such as the Oswestry Disability Index, and a general health survey such as the SF-12 or EQ-5D.  While other scoring systems are numerous, these baseline measures are in widespread use.  These outcomes measures are completed by the patient via a simple questionnaire.  These, along with basic treatment-specific measures such as length of stay, 30-day readmission rate, 90-day re-operation rate, and major complication rates, constitute a core set of outcomes measures that can be collected easily in a busy clinical practice.

This large registry dataset would serve as a starting point from which excellence can be built. Ongoing data collection would allow for rapid assessment of new treatment strategies, whether that is diagnostic, technical, and/or organizational.  Only in this manner can a program truly distinguish itself as a center of excellence.