Anticipated Changes in Spine Practice with Advancing Center for Medicare and Medicaid Services-Required Changes

Is Outpatient Anterior Lumbar Fusion (ALIF) Safe? An Analysis of 30-day Outcomes

STUDY DESIGN

Review of publicly available database.

OBJECTIVE

To compare 30-day outcomes of single-level ALIF procedures performed in outpatient and inpatient settings.

SUMMARY OF BACKGROUND DATA

Despite a growing interest in performing standalone anterior lumbar interbody fusions (ALIFs) as an outpatient procedure, no study has evaluated the safety or efficacy of this procedure outside an inpatient setting.

METHODS

The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was queried using CPT code 22558 to identify patients undergoing a single-level ALIF. Patients receiving concurrent posterior lumbar surgery/fusion/instrumentation, pelvic fixation, or surgery due to tumor, trauma and/or deformity were excluded to capture an isolated cohort of patients receiving single-level standalone ALIFs. A total of 3728 single-level standalone ALIFs were included in the study. Multivariate regression analyses were used to compare 30-day adverse events and readmissions while controlling for baseline clinical characteristics.

RESULTS

Out of a total of 3728 ALIFs, 149 (4.0%) were performed as outpatient procedure. Following adjustment, outpatient ALIFs versus inpatient ALIFs had lower odds of experiencing any 30-day adverse event (2.0% vs. 9.2%, OR 0.24 [95% CI 0.08-0.76]; P =0.015). No significant differences were noted with regard to severe adverse events 9p=0.261), minor adverse events 9p=0.995), and readmission rates ( P =0.95).

CONCLUSION

On the basis of the results of the study, it appears that ALIFs may be carried out safely in an outpatient setting in an appropriately selected patient population.

Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019

BACKGROUND

An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures.

OBJECTIVE

To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010.

METHODS

We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare.

RESULTS

Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements.

CONCLUSION

Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings.

Future endeavors in ambulatory spine surgery

Due to the high societal and financial burden of spinal disorders, spine surgery is thought to be one of the most impactful targets for healthcare cost reduction. One avenue for cost-reduction that is increasingly being explored not just in spine surgery but across specialties is the performance of surgeries in ambulatory surgery centers (ASCs). Despite potential cost-savings, the utilization of ASCs for spine surgery remains largely limited to high-volume centers in the US, and predominantly for single- or two-level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) procedures. Factors most commonly cited for the lack of wider adoption include the risk of life-threatening complications, paucity of guidelines, and limited accessibility of these procedures to various patient populations. Thus, the future growth and adoption of ambulatory spine surgery depends on addressing these concerns by developing evidence-based guidelines for patient- and procedure selection, creating risk-stratification tools, devising appropriate discharge recommendations, and optimizing care protocols to ensure that safety, efficacy and outcomes are maintained. Other avenues that may allow for more widespread use of ASCs include the use of electronic health tools for post-operative monitoring after discharge from the ASC, increasing accessibility of ambulatory procedures to eligible populations, and identifying systemic inefficiencies and implementing process-improvement measures to optimize patient-selection, scheduling and peri-operative management. The success of ambulatory surgery ultimately depends not only on the surgical procedure, but also on its organization upstream and downstream. It provides an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.

Quality Reporting in Neurological Surgery: Practice Adherence to Quality Payment Program Guidelines

Recent legislation has changed quality reporting in neurological surgery. The present study summarizes the reporting of objectives and measures outlined by the Quality Payment Program (QPP) and assesses how practices are preparing to comply. In February 2017, 220 neurosurgical practices were surveyed regarding their adherence to quality reporting objectives and measures. Survey responders were asked to report infrastructure-level data including practice type and number of providers. Furthermore, we evaluated the reporting of quality and advancing care measures outlined by the QPP. Assessment of quality measures was focused on those related to neurosurgical patient management. A total of 27 responses were obtained. Practices consisted of 8 academic (30%), 16 physician-owned (59%), and 3 hospital-owned (11%) neurosurgical practices. Of the 27 total responders, 18 indicated their adherence to a host of quality and advancing care measures. Practice type was strongly associated with the number of quality measures performed (P = .020, Wilcoxon rank-sum test). Physician-owned practices reported performing a median of 5 quality measures (interquartile range, 4.5-9.5), while practices in academic and hospital-owned groups reported performing 12 quality measures (interquartile range, 9.5-13.5). Forty-five percent of physician-owned practices reported performing at least 6 quality measures, whereas 100% of academic and hospital-owned practices reported the same benchmark (P = .038, Fisher's exact test). Performance of advancing care measures was not associated with practice type. Compared to other practice types, the rate of quality reporting among physician-owned neurosurgical practices appears to be modest thus far, which may influence future reimbursement adjustments.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery

BACKGROUND CONTEXT

Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs.

PURPOSE

To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery.

STUDY DESIGN/SETTING

To identify the significant risk factors associated with AOs and to develop risk models that measure performance.

PATIENT SAMPLE

Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset.

OUTCOME MEASURES

The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models.

METHODS

Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals.

RESULTS

There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%.

CONCLUSIONS

Differences among hospitals defines opportunities for care improvement.