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Epstein NE. Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s)? Surg Neurol Int 2023; 14:110. [PMID: 37151427 PMCID: PMC10159315 DOI: 10.25259/sni_175_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background:
Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s: i.e. discharges 4-7.5 hr. postoperatively) that meet the following stringent “exclusion criteria”; elevated Body Mass Index (BMI), major comorbidities, age > 65, American Society of Anesthesiology (ASA) scores > II, and largely multilevel ACDF.
Materials:
Presently, most ACDF are still being performed in hospital-based outpatient surgical centers (HBSC: utilizing 23-hour stays), or as inpatients.
Results:
Notably, unreliable disparate study designs involving very different patient populations resulted in nearly comparable, but implausible outcomes for 1-level vs. multilevel ACDF series performed in ASC. A summary of these outcome data included the following rates of; i.e. postoperative hospital transfers (0-6%), 30-day (up to 2.2%), and up to 90 day (2.2%) emergency department (ED) visits, readmissions, and reoperations.
Conclusion:
Nevertheless, it is just common sense that “less should be less”, that 1-level ACDF should involve less risk compared with multilevel ACDF procedures performed in ASC.
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Bovonratwet P, Kapadia M, Chen AZ, Vaishnav AS, Song J, Sheha ED, Albert TJ, Gang CH, Qureshi SA. Opioid prescription trends after ambulatory anterior cervical discectomy and fusion. Spine J 2023; 23:448-456. [PMID: 36427653 DOI: 10.1016/j.spinee.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND CONTEXT Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSE To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURES Rate, amount, and type of perioperative opioid prescription. METHODS Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTS A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONS Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Milan Kapadia
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Aaron Z Chen
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Avani S Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Todd J Albert
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Catherine H Gang
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
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Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis. Spine (Phila Pa 1976) 2023; 48:155-163. [PMID: 36607626 DOI: 10.1097/brs.0000000000004500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. SUMMARY OF BACKGROUND DATA Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. MATERIALS AND METHODS A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. CONCLUSION Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.
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Gowd AK, Agarwalla A, Beck EC, Derman PB, Yasmeh S, Albert TJ, Liu JN. Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning. Spine (Phila Pa 1976) 2022; 47:1549-1557. [PMID: 36301923 DOI: 10.1097/brs.0000000000004436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/09/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models. BACKGROUND The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care. MATERIALS AND METHODS The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean. RESULTS There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86). CONCLUSIONS Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.
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Affiliation(s)
- Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY
| | - Edward C Beck
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | | | - Siamak Yasmeh
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Todd J Albert
- Department of Orthopedic Surgery, Weill Cornell Medical College, Hospital for Special Surgery, New York, NY
| | - Joseph N Liu
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA
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Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union. J Orthop Trauma 2022; 36:e318-e325. [PMID: 35838557 DOI: 10.1097/bot.0000000000002350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care. DESIGN Retrospective cohort study. SETTING Academic Level II trauma center. PATIENTS All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up. MAIN OUTCOME MEASURES The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care. RESULTS One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004). CONCLUSIONS Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures. LEVEL OF EVIDENCE Economic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Sastry RA, Hagan MJ, Feler J, Shaaya EA, Sullivan PZ, Abinader JF, Camara JQ, Niu T, Fridley JS, Oyelese AA, Sampath P, Telfeian AE, Gokaslan ZL, Toms SA, Weil RJ. Influence of Time of Discharge and Length of Stay on 30-Day Outcomes After Elective Anterior Cervical Spine Surgery. Neurosurgery 2022; 90:734-742. [PMID: 35383699 DOI: 10.1227/neu.0000000000001893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Encouraging early time of discharge (TOD) for medical inpatients is commonplace and may potentially improve patient throughput. It is unclear, however, whether early TOD after elective spine surgery achieves this goal without a consequent increase in re-presentations to the hospital. OBJECTIVE To evaluate whether early TOD results in increased rates of hospital readmission or return to the emergency department after elective anterior cervical spine surgery. METHODS We analyzed 686 patients who underwent elective uncomplicated anterior cervical spine surgery at a single institution. Logistic regression was used to evaluate the relationship between sociodemographic, procedural, and discharge characteristics, and the outcomes of readmission or return to the emergency department and TOD. RESULTS In multiple logistic regression, TOD was not associated with increased risk of readmission or return to the emergency department within 30 days of surgery. Weekend discharge (odds ratio [OR] 0.33, 95% CI 0.21-0.53), physical therapy evaluation (OR 0.44, 95% CI 0.28-0.71), and occupational therapy evaluation (OR 0.32, 95% CI 0.17-0.63) were all significantly associated with decreased odds of discharge before noon. Disadvantaged status, as measured by area of deprivation index, was associated with increased odds of readmission or re-presentation (OR 1.86, 95% CI 0.95-3.66), although this result did not achieve statistical significance. CONCLUSION There does not appear to be an association between readmission or return to the emergency department and early TOD after elective spine surgery. Overuse of inpatient physical and occupational therapy consultations may contribute to decreased patient throughput in surgical admissions.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Matthew J Hagan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Joshua Feler
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Elias A Shaaya
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Patricia Z Sullivan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jose Fernandez Abinader
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Joaquin Q Camara
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Southcoast Health Brain & Spine, Dartmouth, Massachusetts, USA
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Elsamadicy AA, Koo AB, David WB, Freedman IG, Reeves BC, Ehresman J, Pennington Z, Sarkozy M, Laurans M, Kolb L, Shin JH, Sciubba DM. Ramifications of Postoperative Dysphagia on Health Care Resource Utilization Following Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy. Clin Spine Surg 2022; 35:E380-E388. [PMID: 34321392 DOI: 10.1097/bsd.0000000000001241] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim of this study was to investigate patient risk factors and health care resource utilization associated with postoperative dysphagia following elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA There is a paucity of data on factors predisposing patients to dysphagia and the burden this complication has on health care resource utilization following ACDF. METHODS A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016 to 2017. All adult (above 18 y old) patients undergoing ACDF for cervical spondylotic myelopathy were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then categorized by whether they had a recorded postoperative dysphagia or no dysphagia. Weighted patient demographics, comorbidities, perioperative complications, length of hospital stay (LOS), discharge disposition, and total cost of admission were assessed. A multivariate stepwise logistic regression was used to determine both the odds ratio for risk-adjusted postoperative dysphagia as well as extended LOS. RESULTS A total of 17,385 patients were identified, of which 1400 (8.1%) experienced postoperative dysphagia. Compared with the No-Dysphagia cohort, the Dysphagia cohort had a greater proportion of patients experiencing a complication (P=0.004), including 1 complication (No-Dysphagia: 2.9% vs. Dysphagia: 6.8%), and >1 complication (No-Dysphagia: 0.3% vs. Dysphagia: 0.4%). The Dysphagia cohort experienced significantly longer hospital stays (No-Dysphagia: 1.9±2.1 d vs. Dysphagia: 4.2±4.3 d, P<0.001), higher total cost of admission (No-Dysphagia: $19,441±10,495 vs. Dysphagia: $25,529±18,641, P<0.001), and increased rates of nonroutine discharge (No-Dysphagia: 16.5% vs. Dysphagia: 34.3%, P<0.001). Postoperative dysphagia was found to be a significant independent risk factor for extended LOS on multivariate analysis, with an odds ratio of 5.37 (95% confidence interval: 4.09, 7.05, P<0.001). CONCLUSION Patients experiencing postoperative dysphagia were found to have significantly longer hospital LOS, higher total cost of admission, and increased nonroutine discharge when compared with the patients who did not. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Jeff Ehresman
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
| | - Zach Pennington
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
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