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Section 6, Chapter 3: Establishing a Spine Center in Ankara, Turkey

Emre Acaroglu

THE RATIONALE FOR ESTABLISHING A SPINE CENTER (OF EXCELLENCE)

Spine care is probably unique in regard to the diversity associated with it. For almost anyone who is not a spine surgeon, the very concept of spinal surgery raises controversial reactions, ranging from a broad smile to alarm. For health insurance providers (public or private), it is an ever growing black hole that requires more dedicated funds each and every year. For individual health care providers, ranging from hospitals to medical technology companies (Med Tech), conversely, it is an ever growing source of income. Non-surgeon medical care professionals consider it a last resort solution that should be avoided as long as possible. For surgeons, it is not only (one of) the most rational and reproducible methods of treatment but also a major source of income. Although, this very controversy applies to non-surgical treatment of spinal disorders as well. For insurance providers, non-surgical treatment modalities are also associated with significant costs. The period of time over which these costs incur is the main difference between surgery and other treatments. For hospitals as well as the Med Tech companies specializing in non-surgical products, they are a major source of income and revenue. Surgeons tend to consider them costly and ineffective interventions that potentially delay the necessary surgeries and at times make surgery more difficult and costlier. Non-surgeon health care professionals on the other hand think of them as humane and effective strategies that in most instances can prevent an unnecessary and violent surgical intervention. The purpose of this chapter is to discuss whether a holistic approach to spinal disorders may possibly be of assistance in resolving these controversies. Interestingly, all relevant discussion on this subject, be it on the internet or other platforms, seems to disregard the most important element, the person with the spinal problem—the health care beneficiary. Further, this person may or may not be a patient at all. He/she may have something wrong with his/her back, but he/she cannot be sure about the following questions.
  • Is it a disorder or not?
  • If it is a disorder, what is its natural history?
  • Who (which medical professional) should he/she see to have it checked out?
  • Is there a need for a specialist consultation?
  • Is the treatment modality offered indeed appropriate?
In a well-organized health care system, the general practitioner (a.k.a. family doctor), who knows this person, would confirm a real disorder, rule out any emergencies and then, if necessary, direct the patient to the correct health care professional. In real life though, even in very well served areas of the world, this system does not work as effectively as one would expect. The reason for this dysfunction is essentially the same all over the world, regardless of the society’s relative wealth; it is unrealistic to expect a non-specialist to provide any insight beyond triage. Even in well served communities, primary health care professionals are often lost when faced with the seemingly endless treatment options. On the other hand, in underserved areas, primary care physicians may not even exist or, most commonly, may not be a physician but rather a nurse, midwife or a health technician. Either way, the person with the spinal disorder (and the primary care professional) is faced with the number of options schematized in Figure 3-1.
Figure 3-1
FIGURE 3-1. A schematic description of patient flow in a not-well-organized care system. Patients (or referring practitioners) have to make guesses on which medical specialty to apply.
This situation may seem to be less of a problem than it actually is. After all, what could be wrong with having a large number of options? In reality, this choice may profoundly affect the direction, success and the associated costs of a patient’s treatment, because it is likely (although not supported with data) that individuals who initially see a surgeon for their spinal disorder will more likely be offered surgery as a/the treatment option. Conversely, those seeing a physiatrist or a chiropractor will be offered another treatment modalities in lieu of surgery. Even if the specialists in Figure 3-1 refer patients to each other (dotted lines) in pursuit of the ideal or optimum treatment, the referral pattern may prove to be very costly for the patient as well as the health care system. It is these problems that lead to the idea of establishing centers that have the capacity to deliver a multidisciplinary holistic approach. This concept has been developed in several locations almost simultaneously over the last decade. A simple Google search for “spine center” now produces a fair number of hits, mostly located in the well served areas of the world. Figure 3-2 illustrates the advantage of a multidisciplinary center over the more traditional approach seen in Figure 3-1.
Figure 3-2
FIGURE 3-2. A schematic description of the “Patient Focused” approach in a dedicated Spine Center. All stakeholders concentrate on the best interests of patients and evaluate and treat any given patient cooperatively.
In this concept, the person with a spinal problem receives a complete package of services from a multitude of departments that had seemingly been in conflict and in competition for the patient in the previous model. The first step is a quick yet thorough triage in order to rule out any red flags, followed by a series of consultations by diverse disciplines in succession. This person can then fairly safely and quickly be (1) told that there is probably no real danger and his/her condition is very likely to be self-limiting, or (2) told that her condition may not be self-limiting and warrants further treatments that will be implemented in steps starting at the least invasive and potentially ending in surgery, or (3) referred to a surgeon or interventional radiologist for an emergency/urgent/elective intervention if surgery is decidedly the only reasonable solution to his/her problem. Centers that can standardize and implement this approach are generally referred to as “centers of excellence.” The term excellence here is not an abstract self-assigned quality but rather describes that this center has developed the necessary organization for the optimal flow of people and services that apply or have been referred to them. (See Figure 3-3 for a sample flow chart.)
Figure 3-3
FIGURE 3-3. A typical Spine Center flowchart for patients presenting with back pain. As per the virtue of being organized as a center, the patient is led through evaluation and treatment periods with the optimal use of time and resources and minimum chances of missed diagnoses or inappropriate treatments.

Why Ankara?

In addition to a more comprehensive approach to patient care, a center has numerous advantages (and disadvantages) that will be listed and discussed below. But before the discussion of the advantages and disadvantages of this approach in form of a Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis, there is a brief description of the circumstances pertaining to this approach in Ankara, Turkey, a not entirely well served region of the world. Ankara is located at the epicenter of Turkey and does not have any inherent assets like a port, impressive monuments or global reputation. It may be considered a typically large (4 million people) capital of a fairly large (80 million people) middle income country. These qualities are not necessarily related or limited to geographical location (i.e., being in Turkey). There is potentially an Ankara in every region of the world. Parts of Ankara resemble Los Angeles while other parts are more like Dhaka. In this regard, it represents a very common environment, which is not uniformly well served in terms of healthcare but indeed, on the other hand, does have adequate resources and potential to provide a good quality optimal care.

ESTABLISHING A SPINE CENTER IN ANKARA

SWOT Analysis

Strengths

1. A healthcare environment that is transitioning from purely government regulated to mostly private. Over the last decades, Ankara has seen a radical change in the healthcare environment. The system is transitioning (albeit slowly) from the government suppling almost all health insurance and providing almost all healthcare services to the government suppling almost all health insurance but not necessarily providing all services. This approach apparently has potential social disadvantages that are outside of the scope of this chapter. But interestingly, it does have advantages that may be very important and beneficial for patients. At this stage, the advantages are predominantly witnessed as major improvements in the quality of service presentation, such as decreased waiting times, an effectively working appointment system and much better organized emergency services. These changes came along with the introduction of competition into the general picture, and, because of this competition and the dynamic environment associated with it, the system has become more permitting to the introduction of new ideas and concepts. 2. A high supply/low demand period in healthcare during which hospitals may be more inclined to improve the quality of care so as to differentiate themselves from the competitors. The very circumstances described above have also been influential in reversing the supply/demand relationship from a demand dominated one in which hospitals and other healthcare providers, including physicians, were faced with a surplus of demand to a supply dominated one in which, due to a surplus in supply (especially in larger cities, like Ankara), healthcare providers, including physicians, are having to compete for patients. This radical change in milieu has produced the intended effects of: (a) an improvement in the quality of the presentation of health services, and (b) substantial decreases in the costs and prices of healthcare, including pharmaceuticals, implants and, very importantly, physician salaries per unit of service provided. Unfortunately though, it also resulted in the unintended side effect a geometrical increase in the amount of materials and services provided and thus a substantial increase in the overall cost of healthcare. Hence, the presentation of services improved, but costs increased, and the overall medical quality decreased.
Why is this a strength?
It becomes a strength, because, again, it creates an environment in which some stakeholders may be forced to differentiate themselves from the competitors through adapting commonly recognizable tools of quality improvement, one of which is dedicated specialty centers, for the care of spinal disorders in our example here. It is very difficult to claim that this is actually happening perfectly at this point in time, but we can easily say that at least the need and the concept are becoming recognized. 3. A Center may be associated with improved quality of care along with increased cost effectiveness. It is fairly easy to associate a spine center with an increase in the quality of care, in spite of the fact that quality is not readily quantifiable, and therefore there exists no real objective data to substantiate this association. But is it cost effective? Although it is very difficult to answer this question affirmatively without any dispute, there is some indirect evidence suggesting that multidisciplinary high volume centers effectively decrease the morbidity and mortality in spinal deformity surgery,1 as well as complex liver surgery.2 In addition, our experience with the spine center being established in Ankara is that a multidisciplinary approach facilitates implementation of the optimum treatment modality for each and every case, thereby eliminating unnecessary interventions or treatments and decreasing incremental costs. 4. Patients gain access to a large pool of physicians with high quality training. Ankara has a large number of medical schools that have been training and graduating a fairly large number of spine specialists. In fact, this is a fairly common phenomenon in similar cities in similar countries. This intrinsic quality, in turn, becomes a major advantage for an endeavor of establishing a quality based institution. 5. Location is a relatively inexpensive city that is easy to navigate. In quality of living ratings, Ankara had remained at one of the top three positions in Turkey for more than a decade now, consistently faring better than Istanbul. It is a relatively inexpensive city compared to Istanbul as well. In addition, it is better organized and fairly easy to navigate. It is fairly well connected (not as well as Istanbul) and has a modern and not overly crowded airport. Each of these factors is a major strength for a city in which to establish a center.

Weaknesses

1. Hospitals/healthcare providers are reluctant. The need for a specialty center was discussed above. In summary, establishing a (spine) center is a necessity for improving quality of care and potentially increasing cost effectiveness; its purpose is not just to serve upper-income, well-insured patients with better capacity. This necessity is usually not readily realized by major hospitals, especially in cultural environments similar to that in Ankara. The hospital reasons that they had been acting in this field for years now, and, based on this, they know the local environment much better than any person, especially those suggesting radical changes in the way they conduct business. An increase in the number of these institutions to a level of dominance in a region can be seen as a threat. 2. Team and hospital personnel are inexperienced. By definition, a center of excellence is based on teamwork and can only be as strong as its weakest member. The center we have been establishing in Ankara is no exception to this rule and the paucity of quality trained middle medical personnel proved to be a major obstacle to our efforts. This problem of quality training of non-physician medical personnel appears to be very common in similar cultures and countries which may prove to be very difficult to overcome and has the potential to become a permanent weakness and liability. There are several causes but probably the most important one is the education system in general, which focuses on graduating people with vocational skills as opposed to qualified professional personnel. 3. The project is inadequately funded due to a misconception that funding is not required. This is a weakness that we had not anticipated at the time we started with this project. We hoped to engage consultancy services that specialize in similar projects both to assess feasibility and transfer the necessary technology and knowhow in order to establish a quality center. However, the hospital(s) administration rejected the notion that outside consultancy was needed. The authorities believe that they have the expertise to complete this project without assistance from an outside service. Unfortunately, mediocre training, common in similar cultures, may lead to a misunderstanding of the complexity involved in establishing this type of center. It is very difficult to claim that this obstacle has been totally overcome and remains to be a major weakness of and obstacle to establishing spine center in Ankara. 4. The city has inherent weaknesses, including geopolitical turmoil. One thing that we cannot change is the geographical location of Ankara, which introduces significant weaknesses along with opportunities (which will be discussed below). Weaknesses range from the city being relatively plain in terms of popularity as a travel destination as a permanent factor to the major political instability and potential for violence in the neighboring countries as a (hopefully) temporary factor.

Opportunities

1. “Quality” in health care is not being prioritized at any other level or institution in the region. The first institution to introduce a new technology or concept usually acquires a major advantage. This is becoming apparent for establishing a spine center in Ankara as well. As the only comprehensive spine center in the area, it receives a large number of referrals from other spine professionals, because it is regarded as the providing unparalleled care. Non-specific referrals as well as new patient admission have increased at a slower rate, due to the fact that, although spine professionals recognize the quality of care available, notoriety has not yet spread to individuals. 2. Spinal surgery education is not recognized as a priority at any other health care institution in the region. One of the less recognized advantages associated with a spine center is the opportunity it creates in training and education. With the establishment of a spine center in Ankara, the national spine fellowship program that had been sustained for years could be expanded to an international program, especially for potential spine surgeons of orthopaedic or neurosurgery backgrounds from underserved areas of the world (one from Botswana, one from Nepal). Improvement in training quality and quantity between a program run by two individual surgeons compared to an established center proved to be huge and invaluable. 3. There is an increasing demand for high quality patient care and education as well as surgeon education in the country and region. Along with the demand for education and training of health professionals, there is an increasing demand for high quality patient education as well. This has become especially important in the present era of over/misinformation through various online platforms and the media. Establishing a spine center along the principles described above creates an opportunity to fulfil this demand as well, because, by definition, a center with the capacity to delineate optimum individual treatments should have the capacity to provide accurate and impartial spine care information to the patient as well as the general population.

Threats

1. The concept of a “Center of Excellence” is difficult to visualize and/or understand, which creates resistance. As mentioned above, a new concept or technology always encounters resistance before acceptance. This resistance may be very difficult to overcome, because the “new” threatens the positions of powerful stakeholders, and, in order to remain relevant, they may have to undergo radical changes in the way they conduct their practices. This becomes an even more solid and difficult obstacle to overcome when operating in a culture founded on strong beliefs and traditions in which “modernity” as not considered a virtue. 2. The perpetual danger of succumbing to the “good enough” concept of orientalism, which results in leisureliness. This threat is closely related to that discussed above. Orientalism is not a quality specific to the “Orient,” it is very widespread and describes a mentality based on “this may be the correct and ideal way of conduct, but it is too much to be adapted here, our way is good enough for us.” Interestingly, the underserved regions in the relatively developed countries of the world are different from those in the less developed world in this regard. Orientalism is a phenomenon specific to the less developed world and has time and again proven to be a major obstacle in improving the quality of healthcare and services, including education (see the discussion above on the paucity of trained middle personnel). 3. Political and economic instability in the region decreases the mobility of people. This is a geographical and political problem that exists. It is impossible to overcome by individual efforts and shall not be discussed in detail here. Of note, this obstacle is not unique to Ankara and has the potential to affect a wide array of cities and regions all over the world.

CONCLUSIONS AND RECOMMENDATIONS

    • A spine center is a healthcare center which provides a multidisciplinary and holistic treatment approach to people suffering from spinal disorders.
    • A spine center has the potential to improve the quality and patient-centeredness of healthcare. Individualized, optimum care for each and every individual is the target.
    • A spine center has the potential to optimize resource utilization in evaluation and treatment of spinal disorders and increase cost-effectiveness.
    • Establishing a spine center in Ankara, a prototype middle income city, has proven to be possible despite strong weaknesses, threats and obstacles.
    • The key factors for favorable outcome in this endeavor has been perseverance and resistance to obstacles.

REFERENCES