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Nov 30, 2018 - Unified Parkinson's Disease Rating Scale part III (UPDRS-III) in the “on”-. (WHIGET; range 0–52)9 or Fahn-Tolosa-Marin (FTM; range 0–144). Standard-of-care protocol for stereotactic planning for DBS surgery.11.

To develop a process to improve patient outcomes from deep brain stimulation (DBS) surgery for Parkinson disease (PD), essential tremor (ET), and dystonia.We employed standard quality improvement methodology using the Plan-Do-Study-Act process to improve patient selection, surgical DBS lead implantation, postoperative programming, and ongoing assessment of patient outcomes.The result of this quality improvement process was the development of a neuromodulation network. The key aspect of this program is rigorous patient assessment of both motor and non-motor outcomes tracked longitudinally using a REDCap database. We describe how this information is used to identify problems and to initiate Plan-Do-Study-Act cycles to address them. Preliminary outcomes data is presented for the cohort of PD and ET patients who have received surgery since the creation of the neuromodulation network.Careful outcomes tracking is essential to ensure quality in a complex therapeutic endeavor like DBS surgery for movement disorders. The REDCap database system is well suited to store outcomes data for the purpose of ongoing quality assurance monitoring.

Competing Interests: The authors of this manuscript have the following competing interests: R.B. Dewey, III, BS reports no disclosures. O’Suilleabhain, MD reports grants from AVID. Sanghera, PhD reports no disclosures.

Patel, MD reports grants from Adamas. Khemani, MD reports advisory boards with Lundbeck, honoraria from Lundbeck and Dallas School of Neuroscience and Sleep Medicine, and grants from NIH and Once Upon a Time Foundation. Lacritz, PhD reports advisory boards with Teva, honoraria from Omni hotel, John Peter Smith hospital, and Parkland hospital, and grants from NIH/NIA neurobiology of aging and the State of Texas, Texas Alzheimer's Research and Care Consortium. Chitnis, MD, PhD reports consultancies with Teva and Medtronic, advisory boards with Teva, honoraria from Teva, and grants from Teva, Medtronic, NIH, and Allergan. Whitworth, MD reports no disclosures.

Dewey, Jr., MD reports consultancies with Teva, Acadia and Impax, advisory boards with Teva, Acadia, Lundbeck and Impax, honoraria from Teva, Acadia, Impax, Merz, US WorldMeds, Lundbeck, and UCB, and grants from NIH. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Results The result of this quality improvement process was the development of a neuromodulation network.

The key aspect of this program is rigorous patient assessment of both motor and non-motor outcomes tracked longitudinally using a REDCap database. We describe how this information is used to identify problems and to initiate Plan-Do-Study-Act cycles to address them. Preliminary outcomes data is presented for the cohort of PD and ET patients who have received surgery since the creation of the neuromodulation network. Introduction Treatment of disorders such as PD, ET, and dystonia requires an individualized, multi-faceted approach consisting of non-pharmacological therapy, medications, and surgical treatments.

Currently, high frequency deep brain stimulation (DBS) is the most commonly recommended surgical approach when response to medication is inadequate [, ]. DBS consists of an implantable neurostimulation system that creates a non-destructive and reversible disruption of the abnormal activity in the basal ganglia or thalamus to improve motor symptoms [, ]. Selection of the target is based on disease specific considerations including the patient’s most disabling symptoms, as well as co-morbid cognitive and mood symptoms. Once the system is implanted the device is programmed to deliver electrical current to the targeted area.

Randomized trials of DBS in PD report a range of outcomes. Nastavlenie po svyazi vs rf. A recent review tabulated the results of a number of studies of both STN and GPi DBS []. Of the 9 studies reporting on 943 patients undergoing STN DBS, the mean improvement in UPDRS III scores and PDQ-39 index scores ranged from 29–49% and 8.3–26.4% respectively. The same outcome measures for GPi DBS performed in 377 patients showed mean improvements of 29–39% and 6.3–17.5%.

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Possible reasons for a variable response, even at pioneering hospitals where pains have been taken to optimize the processes, include patient differences such as anatomy and physiology at the millimeter scale and operational differences such as the trajectory planning process and the heuristics used to decide a lead location is good enough to quit searching for better. During the early years of our DBS practice, we followed published guidelines on patient selection, surgical technique, and post-operative programming, but there was no systematic collection and review of the outcomes, so there was a missed opportunity to learn based on performance. In the course of routine clinical care we discovered 2 cases of suboptimal clinical responses to DBS, and post-operative imaging confirmed that the leads were not optimally located. These findings prompted a closer look at our DBS program, leading to a quality improvement initiative to refine patient selection, imaging, surgery, and post-operative programming to achieve more consistently positive outcomes. We have implemented Plan-Do-Study-Act (PDSA) cycles as recommended by the Agency for Healthcare Research and Quality for continuous improvement of each component of the DBS pathway []. Parallel and sequential PDSA cycles were undertaken with goals of improving each part of the DBS program as well as the performance of the overall program. In a PDSA cycle, a goal is chosen and literature is reviewed for how best to accomplish this; a process is selected and implemented; results are studied to ascertain if the goal is being accomplished, and if so, the process is retained and another PDSA cycle initiated in another area, but if not, the planning step is undertaken again, this time selecting another change in process aimed at reaching the goal.