Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases

Data Sharing in Neurosurgery and Neurology Journals

In this era of high health care cost and limited research resources, open access to de-identified clinical research study data may promote increased scientific transparency and rigor, allow for the combination and re-analysis of similar data sets, and decrease un-necessary replication of unpublished negative studies. Driven by expanded computing capabilities, advocacy for data sharing to maximize research value is growing in both translational and clinical research communities. The focus of this study is to report on the current status of publicly available research data from studies published in the top 40 neurology and neurosurgery clinical research journals by impact factor. The top journals were carefully reviewed for data sharing policies. Of the journals with data sharing policies, the 10 most current original research papers from December 2015 - February 2016 were reviewed for data sharing statements and data availability. A data sharing policy existed for 48% (19/40) of the 40 journals investigated. Of the 19 journals with an existing data sharing policy, 58% (11/19) of the policies stated that data should be made available to interested parties upon request and 21% (4/19) of these journals encouraged authors to provide a data sharing statement in the article of what data would be available upon request. Of the 190 articles reviewed for data availability, 21% (40/190) of these articles included some source data in the results, figures, or supplementary sections. This evaluation highlights opportunities for neurology and neurosurgery investigators and journals to improve access to study data and even publish the data prospectively for the betterment of clinical outcome analysis and patient care.

Surgeon Reimbursement Relative to Hospital Payments for Spinal Fusion: Trends From 10-year Medicare Analysis

STUDY DESIGN

Retrospective, economic analysis.

OBJECTIVE

The aim of this study was to analyze the trend in hospital charge and payment adjusted to corresponding surgeon charge and payment for cervical and lumbar fusions in a Medicare sample population from 2005 to 2014.

SUMMARY OF BACKGROUND DATA

Previous studies have reported trends and variation in hospital charges and payments for spinal fusion, but none have incorporated surgeon data in analysis. Knowledge of the fiscal relationship between hospitals and surgeons over time will be important for stakeholders as we move toward bundled payments.

METHODS

A 5% Medicare sample was used to capture hospital and surgeon charges and payments related to cervical and lumbar fusion for degenerative disease between 2005 and 2014. We defined hospital charge multiplier (CM) as the ratio of hospital/surgeon charge. Similarly, the hospital/surgeon payment ratio was defined as hospital payment multiplier (PM). The year-wise and regional trend in patient profile, length of stay, discharge disposition, CM, and PM were studied for all fusion approaches separately.

RESULTS

A total of 40,965 patients, stratified as 15,854 cervical and 25,111 lumbar fusions, were included. The hospital had successively higher charges and payments relative to the surgeon from 2005 to 2014 for all fusions with an inverse relation to hospital length of stay. Increasing complexity of fusion such as for anterior-posterior cervical fusion had higher hospital reimbursements per dollar earned by the surgeon. There was regional variation in how much the hospital charged and received per surgeon dollar.

CONCLUSION

Hospital charge and payment relative to surgeon had an increasing trend despite a decreasing length of stay for all fusions. Although the hospital can receive higher payments for higher-risk patients, this risk is not reflected proportionally in surgeon payments. The shift toward value-based care with shared responsibility for outcomes and cost will likely rely on better aligning incentives between hospital and providers.

LEVEL OF EVIDENCE

3.

Outpatient spine surgery: defining the outcomes, value, and barriers to implementation

Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Retrospective single-surgeon study of 1123 consecutive cases of anterior cervical discectomy and fusion: a comparison of clinical outcome parameters, complication rates, and costs between outpatient and inpatient surgery groups, with a literature review

OBJECTIVE Outpatient anterior cervical discectomy and fusion (ACDF) is becoming more common and has been reported to offer advantages over inpatient procedures, including reducing nosocomial infections and costs, as well as improving patient satisfaction. The goal of this retrospective study was to evaluate and compare outcome parameters, complication rates, and costs between inpatient and outpatient ACDF cases performed by 1 surgeon at a single institution. METHODS In a retrospective study, the records of all patients who had undergone first-time ACDF performed by a single surgeon in the period from June 1, 2003, to January 31, 2016, were reviewed. Patients were categorized into 2 groups: those who had undergone ACDF as outpatients in a same-day surgical center and those who had undergone surgery in the hospital with a minimum 1-night stay. Outcomes for all patients were evaluated with respect to the following parameters: age, sex, length of stay, preoperative and postoperative pain (self-reported questionnaires), number of levels fused, fusion, and complications, as well as the presence of risk factors, such as an increased body mass index, smoking, and diabetes mellitus. RESULTS In total, 1123 patients were operated on, 485 (43%) men and 638 (57%) women, whose mean age was 50 years. The mean follow-up time was 25 months. Overall, 40.5% underwent 1-level surgery, 34.3% 2-level, 21.9% 3-level, and 3.2% 4-level. Only 5 patients had nonunion of vertebrae; thus, the fusion rate was 99.6%. Complications occurred in 40 patients (3.6%), with 9 having significant complications (0.8%). Five hundred sixty patients (49.9%) had same-day surgery, and 563 patients (50.1%) stayed overnight in the hospital. The inpatients were older, were more commonly male, and had a higher rate of diabetes. Smoking status did not influence the length of stay. Both groups had a statistically significant reduction in pain (expressed as a visual analog scale score) postoperatively with no significant difference between the groups. One- and 2-level surgeries were done significantly more often in the outpatient setting (p < 0.001). The complication rate was 4.1% in the outpatient group and 3.0% in the inpatient group; there was no statistically significant difference between the 2 groups (p = 0.339). Significantly more complications occurred with 3- and 4-level surgeries than with 1- and 2-level procedures (p < 0.001, chi-square test). The overall average inpatient cost for commercial insurance carriers was 26% higher than those for outpatient surgery. CONCLUSIONS Anterior cervical discectomy and fusion is safe for patients undergoing 1- or 2-level surgery, with a very significant rate of pain reduction and fusion and a low complication rate in both clinical settings. Outpatient and inpatient groups undergoing 3- or 4-level surgery had an increased risk of complications (compared with those undergoing 1- or 2-level surgery), with a negligible difference between the 2 groups. This finding suggests that these procedures can also be included as standard outpatient surgery. Comparable outcome parameters and the same complication rates between inpatient and outpatient groups support both operative environments.

Spine Surgery in the Ambulatory Surgery Center Setting: Value-Based Advancement or Safety Liability?

Here, we systematically review clinical studies that report morbidity and outcomes data for cervical and lumbar surgeries performed in ambulatory surgery centers (ASCs). We focus on anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, cervical arthroplasty, lumbar microdiscectomy, lumbar laminectomy, and minimally invasive transforaminal interbody fusion (TLIF) and lateral lumbar interbody fusion, as these are prevalent and surgical spine procedures that are becoming more commonly performed in ASC settings.

A systematic search of PubMed was conducted, using combinations of the following phrases: “outpatient,” “ambulatory,” or “ASC” with “anterior cervical discectomy fusion,” “ACDF,” “cervical arthroplasty,” “lumbar,” “microdiscectomy,” “laminectomy,” “transforaminal lumbar interbody fusion,” “spine surgery,” or “TLIF.”

In reviewing the available literature to date, there is ample level 3 (retrospective comparisons) and level 4 (case series) evidence to support both the safety and effectiveness of outpatient cervical and lumbar surgery. While no level 1 or 2 (randomized clinical trials) evidence currently exists, the plethora of real-world clinical data creates a formidable argument for serious investments in ASCs for multiple spine procedures.

Discrepancies in the Definition of "Outpatient" Surgeries and Their Effect on Study Outcomes Related to ACDF and Lumbar Discectomy Procedures: A Retrospective Analysis of 45,204 Cases

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

To study the differences in definition of "inpatient" and "outpatient" [stated status vs. actual length of stay (LOS)], and the effect of defining populations based on the different definitions, for anterior cervical discectomy and fusion (ACDF) and lumbar discectomy procedures in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

SUMMARY OF BACKGROUND DATA

There has been an overall trend toward performing ACDF and lumbar discectomy in the outpatient setting. However, with the possibility of patients who underwent outpatient surgery staying overnight or longer at the hospital under "observation" status, the distinction of "inpatient" and "outpatient" is not clear.

MATERIALS AND METHODS

Patients who underwent ACDF or lumbar discectomy in the 2005-2014 ACS-NSQIP database were identified. Outpatient procedures were defined in 1 of 2 ways: either as being termed "outpatient" or hospital LOS=0. Differences in definitions were studied. Further, to evaluate the effect of the different definitions, 30-day outcomes were compared between "inpatient" and "outpatient" and between LOS>0 and LOS=0 for ACDF patients.

RESULTS

Of the 4123 "outpatient" ACDF patients, 919 had LOS=0, whereas 3204 had LOS>0. Of the 13,210 "inpatient" ACDF patients, 337 had LOS=0, whereas 12,873 had LOS>0. Of the 15,166 "outpatient" lumbar discectomy patients, 8968 had LOS=0, whereas 6198 had LOS>0. Of the 12,705 "inpatient" lumbar discectomy patients, 814 had LOS=0, whereas 11,891 had LOS>0. On multivariate analysis of ACDF patients, when comparing "inpatient" with "outpatient" and "LOS>0" with "LOS=0" there were differences in risks for adverse outcomes based on the definition of outpatient status.

CONCLUSIONS

When evaluating the ACS-NSQIP population, ACDF and lumbar discectomy procedures recorded as "outpatient" can be misleading and often did not correlate with same day discharge. These findings have significant impact on the interpretation of existing studies and define an area that needs clarification for future studies.

LEVEL OF EVIDENCE

Level 3.

A Matched Cohort Analysis Comparing Stand-Alone Cages and Anterior Cervical Plates Used for Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare perioperative characteristics of stand-alone cages and anterior cervical plates used for anterior cervical discectomy and fusion (ACDF).

METHODS

We reviewed 40 adult patients who received a stand-alone cage for elective ACDF and matched them with 40 patients who received an anterior cervical plate. We statistically compared operative time, length of stay, proportion of ambulatory cases, overall complications necessitating a trip to the ED, readmission, or reoperation related to index procedure.

RESULTS

There were 21 women and 19 men in the plate cohort with average ages of 53 years ± 12 and 20 women and 20 men in the stand-alone group with an average age of 52 years ± 11. With no statistical difference in total number, the plate group experienced 4 short-term (within 90 days of discharge) complications, including 3 patients who visited the emergency department for dysphagia and 1 who visited the emergency department for severe back pain, while the stand-alone group experienced 0 complications. There was no significant difference in operative time between the stand-alone group (75.35 min) and the plate group (81.35 min; P = .37). There was a significant difference between the proportion of ambulatory cases in the stand-alone group (25) and the plate group (6; P < .0001).

CONCLUSION

Our results demonstrate that stand-alone cages have fewer complications compared to anterior plating, with a lower trend of incidence of postoperative dysphagia. Stand-alone cages may offer the advantage of sending patients home ambulatory after ACDF surgery.

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

BACKGROUND CONTEXT

There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort.

PURPOSE

The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery?

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study.

OUTCOME MEASURES

The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015.

MATERIALS AND METHODS

A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days.

RESULTS

A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23-4.22]; operative time 120-180 minutes, OR: 1.77 [95% CI 1.27-2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66-3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08-15.48] and OR: 2.79 [1.40-5.56], respectively).

CONCLUSIONS

Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

Best Practices for Outpatient Anterior Cervical Surgery: Results From a Delphi Panel

STUDY DESIGN

Delphi Panel expert panel consensus and narrative literature review.

OBJECTIVE

To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)).

SUMMARY OF BACKGROUND DATA

Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings are lacking.

METHODS

A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Predetermined consensus was set at 70% for each best-practice statement.

RESULTS

A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and subcategories) achieved consensus, including preoperative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6).

CONCLUSION

This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment.

LEVEL OF EVIDENCE

4.

Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost

BACKGROUND

Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission.

OBJECTIVE

To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF.

METHODS

Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.

RESULTS

A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients (P &lt; .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P &lt; .05; inpatient OR 1.289, P &lt; .0001) and readmission (ambulatory OR 1.746, P &lt; .0001; inpatient OR 1.685, P &lt; .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P &lt; .0001).

CONCLUSION

ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.

Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.

METHODS

An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.

CONCLUSION

We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

LEVEL OF EVIDENCE

5.

Economic Analysis and Patient Satisfaction Associated With Outpatient Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is a rapidly growing treatment for end-stage ankle arthritis that is generally performed as an inpatient procedure. The feasibility of outpatient total ankle arthroplasty (OTAA) has not been reported in the literature. We sought to establish proof of concept for OTAA by comparing outpatient vs inpatient perioperative complications, postoperative emergency department (ED) visits, readmissions, patient satisfaction, and cost analysis.

METHODS

From July 2010 to September 2015, a total of 36 patients underwent TAA. Patients with prior ankle replacement, prior ankle infections, neuroarthropathy, or osteonecrosis of the talus were excluded from the study. All patient demographics, tourniquet times, estimated blood loss, comorbidities, concomitant procedures, complications, return ED visits, and readmissions were recorded. Patient satisfaction questionnaires were collected. Twenty-one patients had outpatient surgery and 15 had inpatient surgery. The cohorts were matched demographically.

RESULTS

The average length of stay for the inpatient group was 2.5 days. The overall cost differential between the groups was 13.4%, with the outpatient group being less costly. This correlates to a cost savings of nearly $2500 per case. One patient in the outpatient group had a return ED visit on postoperative day 1 for urinary retention. There were no 30-day readmissions in either group. Seventy-one percent of the outpatient group and 93% of the inpatient group would not change to a different postoperative admission status if they were to have the procedure again.

CONCLUSION

Our results show that OTAA was a cost-effective and safe alternative with low complication rates and high patient satisfaction. With proper patient selection, OTAA was beneficial to both the patient and the health care system by driving down total cost. It has the capacity to generate substantial savings while providing equal or better value to the patient.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Inpatient versus Outpatient Anterior Cervical Discectomy and Fusion: A Perioperative Complication Analysis of 259,414 Patients From the Healthcare Cost and Utilization Project Databases

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is one of the most common operations utilized to address pathology of the cervical spine. Few reports have attempted to compare complications associated with inpatient versus outpatient ACDF.

METHODS

The Nationwide Inpatient Sample (NIS) from 2001-2012 and the State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 were used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were segmented into an inpatient group derived from the NIS, and an outpatient group derived from the NJ SASD. Patients receiving > 2 levels fused (ICD-9 codes 81.63-81.64), or surgery for cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of medical diagnoses.

RESULTS

Of the 94,492,438 inpatients comprising the NIS from 2001-2012, 257,398 received ACDF. Of the 4,194,207 outpatients comprising the NJ SASD, 2,016 received ACDF. PSM of 10,080 patients (all 2,016 SASD and 8,064 from NIS) was performed, and subsequent analysis revealed that durotomy (P=0.001;OR=0.81), paraplegia, postoperative infection, hematoma/seroma (OR=0.14), respiratory complications, acute posthemorrhagic anemia and red blood cell transfusion (all P<0.001) were less frequent in outpatient versus inpatient ACDF (p<0.05). These results were similar to an unmatched analysis involving all of the NIS patients.

CONCLUSION

Accepting the limitations of the NIS and SASD (inability to distinguish between one and two-level fusions, no long-term follow-up, potential selection bias, disparities between inpatient and outpatient ACDF populations), these findings indicate that for 1-2 level ACDF, perioperative complications, including durotomy, paraplegia, hematoma, and acute posthemorrhagic anemia were more commonly reported following inpatient ACDF. Future studies involving outpatient analysis of several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.

Creating Leverage to Counter Threats to Neurosurgical Practice

This article describes guiding principles utilized in practice. It is descriptive of the evolution of one of the largest neurosurgical practices in the United States. The objective is to identify and effectively create leverage in neurosurgical practice and to describe principles instrumental in the growth of this practice.Methods included data collection, responsiveness, recruitment, and innovation. Results demonstrate important strategies for creating and maintaining leverage, as well as principles that have enabled the practice to remain independent and continue to provide high-quality care.In conclusion, it is important to stay focused on potential sources of leverage, to gain advantage for the future, and maintain stability as healthcare changes occur. Quality data and outcomes will allow practice to continue to grow strategically.

Outpatient Anterior Cervical Discectomy and Fusion: An Analysis of Readmissions from the New Jersey State Ambulatory Services Database

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) performed as an outpatient has become increasingly common for treating cervical spine pathology. Few reports have attempted to assess readmissions following outpatient ACDF. This study was performed to address this issue using population-based databases.

METHODS

The State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 was used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were extracted; those with three or more levels fused (ICD-9 codes 81.63-81.64), cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. A series of perioperative complications including durotomy, red blood cell transfusion, acute posthemorrhagic anemia, paraplegia (weakness), and mortality were examined. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of diagnoses. The NJ SASD defined readmission as admission to the same facility within seven days of initial discharge.

RESULTS

Two thousand sixteen (2,016) patients were found, 1,528 of whom had readmission data. Of these 1,528 patients, 83 (5.4%) required readmission. PSM was performed prior to comparing readmission versus non-readmission. While there was no difference in perioperative complications between the two groups, the small sample size of the readmission cohort prevented this analysis from having sufficient power. No patient requiring readmission had an initial length of stay greater than one day.

CONCLUSION

Based on a 10-year outpatient analysis, fewer than 6% of outpatient 1-2 level ACDFs require readmission. Future studies involving outpatients from several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.

Safety and Outcomes of Inpatient Compared with Outpatient Surgical Procedures for Ankle Fractures

BACKGROUND

As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal.

METHODS

Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes.

RESULTS

Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 [95% confidence interval, 0.201 to 0.589]). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358).

CONCLUSIONS

In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cervical spine surgery performed in ambulatory surgical centers: Are patients being put at increased risk?

Background:

Spine surgeons are being increasingly encouraged to perform cervical operations in outpatient ambulatory surgical centers (ASC). However, some studies/data coming out of these centers are provided by spine surgeons who are part or full owners/shareholders. In Florida, for example, there was a 50% increase in ASC (5349) established between 2000–2007; physicians had a stake (invested) in 83%, and outright owned 43% of ASC. Data regarding “excessive” surgery by ASC surgeon-owners from Idaho followed shortly thereafter.

Methods:

The risks/complications attributed to 3279 cervical spine operations performed in 6 ASC studies were reviewed. Several studies claimed 99% discharge rates the day of the surgery. They also claimed major complications were “picked up” within the average postoperative observation window (e.g., varying from 4–23 hours), allowing for appropriate treatment without further sequelae.

Results:

Morbidity rates for outpatient cervical spine ASC studies (e.g. some with conflicts of interest) varied up to 0.8–6%, whereas morbidity rates for 3 inpatient cervical studies ranged up to 19.3%. For both groups, morbidity included postoperative dysphagia, epidural hematomas, neck swelling, vocal cord paralysis, and neurological deterioration.

Conclusions:

Although we have no clear documentation as to their safety, “excessive” and progressively complex cervical surgical procedures are increasingly being performed in ASC. Furthermore, we cannot rely upon ASC-based data. At least some demonstrate an inherent conflict of interest and do not veridically report major morbidity/mortality rates for outpatient procedures. For now, cervical spine surgery performed in ASC would appear to be putting patients at increased risk for the benefit of their surgeon-owners.

Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis

Background

Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries and neurosurgical procedures performed to treat a variety of disorders in the cervical spine. Over the last several years, ACDF has been done in the outpatient setting for less invasive approaches and exposures, as well as modified anesthetic and pain management techniques. Despite the fact that it may be innocuous in other parts of the body, complications in the spine can literally be fatal. The objective of this article is to evaluate the safety of outpatient surgery compared with inpatient surgery in the cervical spine for adult patients.

Methods

The multiple databases including Pubmed, Springer, EMBASE, EBSCO and China Journal Full-text Database were adopted to search for the relevant studies in English or Chinese. Full-text articles involving to the safety of outpatient cervical spine surgery were selected. Review Manager 5.0 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted. Chi-square tests were conducted with SPSS 20.0 software.

Results

Finally, 12 articles were included. The results of meta-analysis suggested that in the articles included, no death occurred, and compared with inpatient surgery, outpatient surgery has a similar risk (RR = 0.99, 95 % CI [0.98, 1.00], P = 0.02; P for heterogeneity = 0.47, I² = 0 %). An I² value of 0 % indicates no heterogeneity observed. All complications were occurred in both outpatients and inpatients. Among the studies selected, after the outpatient spine surgery, the highest incidences of complication were dysphagia (18/29) and hematoma (4/29). Compared with the overall complication rate in inpatient group, no significant difference was observed (x² = 1.820, P = 0.177).

Conclusion

In this study, outpatient surgery has a similar risk with inpatient surgery, and no difference of morbidity between outpatient and inpatient was found. Because of short operative time and moderate postoperative pain, we believe that outpatient cervical spine surgery is a safe and convenient alternative procedure, which also decrease the cost of care. Besides, postoperative complications including dysphagia and hematoma should be noticed.