Outpatient Neurosurgery: ASCs and the Medicolegal Landscape

The purpose of this work is to provide an understanding of the medicolegal landscape with regards to ambulatory surgery centers and physician owned hospitals, trends in our healthcare system, the benefits of facility ownership for both outpatient and inpatient spine surgery, and the effect of each on physicians and patients.

Outcomes and Cost-Effectiveness of Hospital Outpatient Versus Ambulatory Surgery Center Lumbar Decompression Surgery

STUDY DESIGN

Retrospective Chart Review.

OBJECTIVES

Outpatient spinal surgeries in Ambulatory Surgery Centers (ASCs) have gained traction due to their potential cost efficiencies and improved perioperative processes. This study aims to compare the cost-effectiveness and patient outcomes of lumbar laminectomies performed in hospital settings vs ASCs.

METHODS

A retrospective analysis was conducted on 771 patients who underwent 1 or 2-level outpatient laminectomy between 2019 and 2023. Patient demographics, 90-day and one-year clinical and patient-reported outcomes (PROs), and one-year episode of care costs were evaluated. A one-year cost-effectiveness analysis was performed using the EQ-5D to measure quality-adjusted life years (QALYs).

RESULTS

ASC patients demonstrated lower body mass index and American Society of Anesthesiologists (ASA) scores, with a higher prevalence of 1-level laminectomies compared to hospital patients. ASC-based laminectomy was associated with lower initial surgery cost and one-year episode of care costs ($5662 ± 4748 vs $10229 ± 9202, P < 0.001), with similar rates of complications and postoperative resource utilization. These trends remained after controlling for patient demographics, comorbidities, and number of levels treated. In patients completing baseline and 1-year EQ-5D scores, ASC-based laminectomy was over twice as cost-effective as hospital procedures ($64873/QALY gained vs $152630).

CONCLUSIONS

The findings support the safety and one-year cost effectiveness of ASCs for appropriately selected patient populations undergoing lumbar laminectomy. Additional studies are needed to replicate these findings across institutions, and to assess the cost effectiveness of ASC-based laminectomy beyond one-year postoperatively.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXT

Perioperative pain management affects cost and outcomes in elective spine surgery.

PURPOSE

This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization.

STUDY DESIGN

This was a retrospective comparative study.

PATIENT SAMPLE

Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores.

OUTCOME MEASURES

Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis.

METHODS

Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc.

RESULTS

In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts.

CONCLUSIONS

Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Performance of successful ambulatory cervical spine surgery: safety, efficacy, and early experiences of first 100 cases in Poland

BACKGROUND

Ambulatory anterior cervical discectomy and fusion (ACDF) is a promising method, but not common in Poland.

OBJECTIVE

That is why the purpose of this study was to demonstrate the experience of performing ACDF in patients with degenerative spinal diseases.

METHODS

This study at the Spine Centre involved a single-center, multi-surgeon evaluation of 100 patients undergoing ACDF.

RESULTS

Outcomes assessed included pain severity, measured by the visual analogue scale, which improved from 4.28 ± 0.76 preoperatively to 1.11 ± 0.59 one month postoperatively. The Core Outcome Measures Index-neck (COMI-neck) scale also showed significant improvement: before surgery, 30% of patients scored their condition severity between 4-6, and 70% scored 7-10; 6 months postoperatively, the scores were 0-3 for 55% of patients, 4-6 for 45%, and 7-10 for none. Only 2% of patients experienced moderate, temporary complications, with no serious complications or postoperative hematomas observed.

CONCLUSION

The study supports the feasibility, safety, and efficacy of performing ACDF in an ambulatory setting, suggesting that with appropriate patient selection and surgical protocols, ambulatory ACDF can be more broadly implemented.

Growing utilization of ambulatory spine surgery in Medicare patients from 2010-2021

Background

There is growing interest in transitioning various surgical procedures to the outpatient care setting. However, for Medicare patients, the site of service for surgical procedures is influenced by regulations within the Inpatient and Outpatient Prospective Payment Systems. The purpose of this study is to quantify changes in utilization of outpatient spine surgery within the Medicare population, as well as to determine changes in outpatient volume after removal of a procedure from the "inpatient-only" list.

Methods

This is a cross-sectional study of Medicare billing database information for selected spine procedures included in the Medicare Physician/Supplier Procedure Summary (PSPS) public use files from 2010-2021. These files include aggregated data from Medicare Part B fee-for-service claims, published yearly. Procedures from Healthcare Common Procedural Coding System (HCPCS) code ranges 22010-22899 and 62380-63103 were selected for analysis, limited to surgical services delivered in the inpatient, hospital outpatient department (HOPD), and ambulatory surgical center (ASC) settings. For each HCPCS code included, estimates of the total number of services and corresponding changes in volume were calculated.

Results

Within the range of codes included in the study, the total number of outpatient spine procedures rose approximately 193% from 2010 to 2021, with compound annual growth rate (CAGR) for outpatient procedures per year of 9.9% for HOPDs and 15.7% for ASCs (-2.2% for inpatient procedures). Within this period, the ASC list grew from 12 procedures to 58 procedures. In 2021, the highest volume ASC procedure was HCPCS 63047, at approximately 4970 procedures.

Conclusions

This study demonstrates a trend of increasing utilization of HOPDs and ASCs for spine procedures among Medicare beneficiaries from 2010 to 2021. Though HOPDs are currently more widely utilized, the ongoing additions of spine procedures to the ASC covered procedures list may shift this balance.

Outpatient Spine Procedures in Poland: Clinical Outcomes, Safety, Complications, and Technical Insights into an Ambulatory Spine Surgery Center

PURPOSE

This study evaluated the safety and efficacy of spine procedures performed in an ambulatory spine surgery unit in Poland.

PATIENTS AND METHODS

We conducted a retrospective analysis of 318 patients who underwent ambulatory spine surgery between 2018 and 2021, with procedures including microdiscectomy (MLD), anterior cervical discectomy and fusion (ACDF), endoscopic interbody fusion (endoLIF), posterior endoscopic cervical discectomy (PECD), interlaminar endoscopic lumbar discectomy IELD, and transforaminal endoscopic lumbar discectomy (TELD). Patient data were analyzed for pre-operative and post-operative visual analog scale (VAS) scores.

RESULTS

The findings indicated that outpatient techniques were safe and effective, with a 2.83% complication rate. All procedures significantly improved VAS scores under short-term observation, and core outcome measurement index (COMI) scores under long-term observation.

CONCLUSIONS

Ambulatory spine surgery represents a relatively new approach in Poland, with only a select few centers currently offering this type of service. Outpatient spine surgery is a safe, effective, and cost-effective option for patients requiring basic spine surgeries.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers

PURPOSE

To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy.

METHODS

The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1.

RESULTS

The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy.

CONCLUSIONS

ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Outpatient minimally invasive spine surgeries during the COVID-19 pandemic - A retrospective analysis of 164 consecutive cases

Objective

To share our surgical experiences of minimally invasive cervical and lumbar procedures for patients who suffered from non-fatal motor vehicle accidents (MVAs) in the ambulatory surgery centers (ASCs) during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), minimally invasive laminotomy and discectomy (MILD), percutaneous endoscopic laser-assisted discectomy (PELD) and percutaneous kyphoplasty (PK) were performed on carefully selected patients.

Results

From January 2020 to December 2021, our group performed 164 cases on 153 patients involving 249 intervertebral disc (IVD) levels. Of these, 116 cases (70.73%) on 114 patients (74.51%) were cervical, 48 cases (29.27%) were lumbar (including 8 PK cases). Eight patients had both cervical and lumbar procedures in a single anesthetic session (SAS) and were discharged on the same day. One hundred and six ACDF cases (92.17%) were at the C4-C5 and C5-C6 levels, which comprised of 146 (76.04%) IVDs. Of the 40 non-PK lumbar cases, 38 (95.0%) were at L4 to S1 lumbar levels. Six of these cases (15.0%) involved 2 lumbar levels. In contrast, 6 out of 8 kyphoplasties (75.0%) involved lower thoracic/higher lumbar vertebral columns (T11 to L2) and 2 were at the lower lumbar L4 level.

Conclusions

We successfully and safely performed various cervical and lumbar spine surgeries in the ASCs amid COVID-19 pandemic and all patients achieved the same-day discharge (SDD). In the non-fatal MVAs, mid-lower cervical (C4 to C6) and lower lumbar (L4 to S1) IVDs were the most affected levels.

Economic comparisons of endoscopic spine surgery: a systematic review

PURPOSE

Full-endoscopic techniques are minimally invasive surgery alternatives to traditional spinal surgery. We performed a systematic review of the literature to assess the costs of these techniques compared to traditional approaches.

METHODS

A systematic review of the literature was performed for economic evaluations that compare endoscopic decompressions of the lumbar spine for stenosis or disc herniation to open or microsurgical decompressions. The search was performed in the following databases: Medline, Embase Classic, Embase, and Central Cochrane library, from January 1, 2005, to October 22, 2022. The included studies were each evaluated according to a formal assessment checklist to evaluate the quality of economic evaluations based on 35 criteria.

RESULT

A total of 1153 studies were identified, with 9 articles included in the final analysis. In evaluating the quality of economic evaluations, the study with the fewest met criteria scored 9/35 and the study with the most met criteria scored 28/35. Only 3 studies completed cost-effectiveness analyses. Surgical procedure duration varied between studies, but hospital length of stays were consistently shorter with endoscopy. While endoscopy was more frequently associated with higher operating costs, studies that measured healthcare and societal costs found endoscopy to be advantageous.

CONCLUSION

Endoscopic spine surgery was found to be cost-effective in treating patients with lumbar stenosis and disc herniation when compared to standard microscopic approaches from a societal perspective. More well-designed economic evaluations investigating the cost-effectiveness of endoscopic spine procedures are needed to further support these findings.

Patient Perceptions of Paramedian Minimally Invasive Spine Skin Incisions

BACKGROUND

In clinical outcome studies, patient input into the factors that drive higher satisfaction with lumbar minimally invasive spinal surgery (MISS) is rare. The skin incision is often the only visible consequence of surgery that patients can assess. The authors were interested in patients' opinions about the type of lumbar paramedian minimally invasive spinal (MIS) skin incision employed during MISS and how novel skin incisions could impact patients' interpretation of the outcome. The authors wanted to compare traditional lumbar stab incisions to three novel lumbar paramedian (MIS) skin incisions to determine if further study is indicated. The primary objective was to examine patient satisfaction and perceptions regarding lumbar paramedian MIS skin incisions.

METHODS

We reviewed the literature and conducted a patient opinion survey. Responses were solicited from back pain patients from a single chiropractic office. Survey questions regarding novel skin incisions for minimally invasive spine surgery (NSIMISS) were conceptualized. The three novel skin incisions were designed using Langer's lines to reduce the total number of incisions; improve patient satisfaction; increase ease of surgical approach/fixation; and reduce operative time/radiation exposure.

RESULTS

One hundred and six participants were surveyed. When shown traditional lumbar paramedian MIS skin stab incisions, 76% of respondents indicated negative responses, n = 65. The majority of patients chose traditional stab incisions (n = 41) followed by novel larger intersecting incisions (n = 37). The least popular incisions were the novel horizontal (n = 20) and the novel mini oblique (n = 5) incisions. Female patients worried more than male patients about how their incision looked. However, there was no statistically significant difference (p value of 0.0418 via Mann-Whitney U one-tailed test and p value of 0.0836 via Mann-Whitney U two-tailed test). Patients less than or equal to 50 years of age worried more than patients over 51 years of age, which was statistically significant (p value of 0.0104 via Mann-Whitney U one-tailed test and p value of 0.0208 via Mann-Whitney U two-tailed test).

CONCLUSIONS

Patients do have opinions on the type of lumbar paramedian MIS skin incision used. It appears that younger patients and female patients worry most about how the incision on their back looks after surgery. A larger population of patients across many demographics is needed to validate these findings.

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.

Creation of a Risk Calculator for Predicting New-Onset Cardiac Arrhythmias in Patients Undergoing Lumbar Fusion

INTRODUCTION

As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection.

METHODS

A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia.

RESULTS

A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733.

CONCLUSION

A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions.

Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 2: Assessment of Surgical Safety in Medicare Beneficiaries

(1) Background: The clinical benefits and procedural efficiencies of performing minimally invasive fusion procedures, such as transforaminal lumbar interbody fusion (TLIF), in the ambulatory surgery center (ASC) are becoming increasingly well established. Currently, Medicare does not provide reimbursement for its beneficiaries eligible for TLIF in the ASC due to a lack of evidence regarding procedural safety. However, the initiation of the Hospital Without Walls program allowed for traditional hospital procedures to be relocated to other facilities such as ASCs, providing a unique opportunity to evaluate the utility of TLIF in the ASC in Medicare-age patients. (2) Methods: This single-center, retrospective study compared baseline characteristics, intraoperative variables, and 30-day postoperative safety outcomes between 48 Medicare-age patients undergoing TLIF in the ASC and 48 patients having the same procedure as hospital in-patients. All patients had a one-level TLIF using the VariLift^®-LX expandable lumbar interbody fusion device. (3) Results: There were similar patient characteristics, procedural efficiency, and occurrence of clinical 30-day safety events between the two study groups. However, there was a marked and statistically significant difference in the median length of stay favoring TLIF patients treated in the ASC (23.9 h vs. 1.6 h, p = 0.001). All ASC-treated patients were discharged on the day of surgery. Postoperative visits to address adverse events were rare in either group. (4) Conclusions: These findings provide evidence that minimally invasive TLIF can be performed safely and efficiently in the ASC in Medicare-age patients. With same-day discharge, fusion procedures performed in the ASC offer a similar safety and more attractive cost-benefit profile for older patients than the same surgery undertaken in the traditional hospital setting. The Centers for Medicare and Medicaid Services should strongly consider extending the appropriate reimbursement codes (CPT ^® 22630, 22633) for minimally invasive TLIF and PLIF to the ASC Covered Procedure List so that Medicare-age patients can realize the clinical benefits of surgeries performed in this setting.

Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 1: Multi-Center Assessment of Surgical Safety

(1) Background: The technological advances achieved with minimally-invasive surgery have enabled procedures to be undertaken in outpatient settings, and there has been growing acceptance of performing minimally-invasive transforaminal interbody fusion (TLIF) in the ambulatory surgery center (ASC). The purposeof this study was to determine the comparative 30 day safety profile for patients treated with TLIF in the ASC versus the hospital setting. (2) Methods: This multi-center study retrospectively collected baseline characteristics, perioperative variables, and 30 day postoperative safety outcomes for patients having a TLIF using the VariLift^®-LX expandable lumbar interbody fusion device. Outcomes were compared between patients undergoing TLIF in the ASC (n = 53) versus in the hospital (n = 114). (3) Results: Patients treated in-hospital were significantly older, frailer and more likely to have had previous spinal surgery than ASC patients. Preoperative back and leg pain scores were similar between study groups (median, 7). ASC patients had almost exclusively one-level procedures (98%) vs. 20% of hospital procedures involving two-levels (p = 0.004). Most procedures (>90%) employed a stand-alone device. The median length of stay for hospital patients was five times greater than for ASC patients (1.4 days vs. 0.3 days, p = 0.001). Emergency department visits, re-admissions and reoperations were rare whether the patients were managed in the traditional hospital setting or the ASC. (4) Conclusions: There were equivalent 30 day postoperative safety profiles for patients undergoing a minimally-invasive TLIF irrespective of surgical setting. For appropriately selected surgical candidates, the ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.

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.

Biomechanical Evaluation of Transforaminal Lumbar Interbody Fusion with Coflex-F and Pedicle Screw Fixation: Finite Element Analysis of Static and Vibration Conditions

OBJECTIVE

To investigate the biomechanics of transforaminal lumbar interbody fusion (TLIF) with interspinous process device (IPD) or pedicle screw fixation under both static and vibration conditions by the finite element (FE) method.

METHOD

A validated FE model of the L1-5 lumbar spine was used in this study. This FE model derived from computed tomography images of a healthy female adult volunteer of appropriate age. Then the model was modified to simulate L3-4 TLIF. Four conditions were compared: (i) intact; (ii) TLIF combined with bilateral pedicle screw fixation (BPSF); (iii) TLIF combined with U-shaped IPD Coflex-F (CF); and (iv) TLIF combined with unilateral pedicle screw fixation (UPSF). The intact and surgical FE models were analyzed under static and vibration loading conditions respectively. For static loading conditions, four motion modes (flexion, extension, lateral bending, and axial rotation) were simulated. For vibration loading conditions, the dynamic responses of lumbar spine under sinusoidal vertical load were simulated.

RESULT

Under static loading conditions, compared with intact case, BPSF decreased range of motion (ROM) by 92%, 95%, 89% and 92% in flexion, extension, lateral bending and axial rotation, respectively. While CF decreased ROM by 87%, 90%, 69% and 80%, and UPSF decreased ROM by 84%, 89%, 66% and 82%, respectively. Compared with CF, UPSF increased the endplate stress by 5%-8% in flexion, 7%-10% in extension, 2%-4% in lateral bending, and decreased the endplate stress by 16%-19% in axial rotation. Compared with CF, UPSF increased the cage stress by 9% in flexion, 10% in extension, and decreased the cage stress by 3% in lateral bending, and 13% in axial rotation. BPSF decreased the stress responses of endplates and cage compared with CF and UPSF. Compared BPSF, CF decreased the facet joint force (FJF) by 6%-13%, and UPSF decreased the FJF by 4%-12%. During vibration loading conditions, compared with BPSF, CF reduced maximum values of the FJF by 16%-32%, and vibration amplitudes by 22%-35%, while UPSF reduced maximum values by 20%-40%, and vibration amplitudes by 31%-45%.

CONCLUSION

Compared with other surgical models, BPSF increased the stability of lumbar spine, and also showed advantages in cage stress and endplate stress. CF showed advantages in IDP and FJF especially during vertical vibration, which may lead to lower risk of adjacent segment degeneration. CF may be an effective alternative to pedicle screw fixation in TLIF procedures.

Effect of a Mandatory Prescription Drug Monitoring Program on Patient-initiated Phone Calls After Spine Surgery

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to determine the effect of a statewide, government-mandated prescription drug monitoring program (PDMP) on patient-initiated phone calls after lumbar and cervical spinal surgery.

SUMMARY OF BACKGROUND DATA

Prior studies have examined the most common reasons for a postoperative phone calls, most of which pertain to pain or prescription medications. However, no studies have investigated the effects of mandatory opioid prescription reporting on these calls.

METHODS

Patients who underwent lumbar decompression, lumbar fusion, or posterior cervical fusion were retrospectively identified. Patients were sorted into 1 of 2 cohorts based on their procedure date's relation to the initiation of the state's PDMP: "pre-PDMP" and "post-PDMP." All clinical and demographic data were obtained from electronic health records. Telephone communications from or on behalf of patients were retrospectively reviewed. Multivariable logistic regression was performed to determine independent factors associated with a postoperative phone call.

RESULTS

Five hundred and twenty-five patients (2689 phone calls) were included in the study. Average number of phone calls per patient increased significantly after PDMP implementation among lumbar (3.27 vs. 5.18, P<0.001), cervical (5.08 vs. 11.67, P<0.001), and all (3.59 vs. 6.30, P<0.001) procedures. Age [odds ratio (OR): 1.05 (1.01, 1.09), P=0.02], cervical procedure [OR: 4.65 (1.93, 11.21), P=0.001], and a post-PDMP date of surgery [OR: 6.35 (3.55, 11.35), P<0.001] were independently associated with an increased likelihood of a postoperative phone call. A higher percentage of calls were in reference to postoperative care (4.6% vs. 2.4%, P=0.01) and wound care (4.3% vs. 1.4%, P<0.001) in the post-PDMP cohort compared with the pre-PDMP cohort.

CONCLUSIONS

Patient-initiated telephone calls increased significantly after implementation of a mandatory statewide PDMP. Increasing age, operation involving the cervical spine, and surgery occurring after implementation of the state's PDMP were independently associated with an increased likelihood of postoperative phone call to health care providers.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Safety and feasibility of same-day discharge following lumbar decompression surgery: A systematic review

Introduction

Lumbar decompression (LD) surgery, with or without discectomy, is a commonly performed surgical procedure. Despite the concept of day-case LD being reported as early as the 1980s, day-case LD is yet to become routine clinical practice.

Research question

This systematic review aimed to examine the published literature on the safety and complication rates of day-case LD. Secondary outcome measures, including the economic impact and patient satisfaction of day-case LD, were also examined.

Materials and methods

A systematic electronic search was carried out on PubMed, EMBASE and the Cochrane Library between 1999 and January 2022. Studies were screened against predefined inclusion/exclusion criteria with the quality of included studies subsequently being assessed.

Results

In total, 15 studies were included in this review. The majority of studies were undertaken in the USA (n ​= ​8, 53%) and were of a case series design (n ​= ​9, 60%). Reported complication rates ranged from 0% to 7.8%, with nine studies reporting a complication rate of <4%. Readmission rates ranged from 0% to 7.7%. Seven studies quoted a readmission rate of 0%. Five studies found cost saving benefits of day-case LD in comparison to inpatient LD of up to $27,984 (USD). Patient acceptability of day-case LD was consistently high across the six studies that assessed it.

Discussion and conclusion

Day-case LD surgery is a safe and economically efficient surgical option in appropriately selected patients.

A Virtual Hybrid Care Hotel Model Supports the Recovery of Post-procedural Patients with Mild to Severe Systemic Diseases

BACKGROUND

Patients with mild to severe chronic systemic disease undergoing low-risk procedures are often hospitalized for observation. The Care Hotel is a novel virtual medicine hybrid model of care that offers patients a comfortable, out of hospital environment where they can receive both in-person and virtual care after a surgery or procedure. This study aimed to analyze if virtual hybrid post-procedure care in a hotel could be both conducted on and accepted by patients, even those with moderate to severe chronic diseases.

METHODS

This retrospective cohort study was conducted between July 23, 2020 and June 4, 2021 at Mayo Clinic in Florida, a 306-bed community academic hospital. We collected the sex, age, race, ethnicity, acceptance rate, ASA score, and primary procedure of patients using the Care Hotel.

RESULTS

Out of 392 patients, 272 (69.4%) opted for care in the program. Median patient age was 61.5 years, 59.56% were males, and 86.40% were white. We found that 50.37% had an ASA score of 2 and 43.4% had an ASA score of 3. Ten different surgical specialties were able to utilize the Care Hotel for care in 47 different procedure types. Urology had the most patients (n=70, 25.7%). Post-electrophysiologic procedures were the most common procedures (n=39, 14.3%).

CONCLUSION

Our virtual hybrid Care Hotel program was widely accepted by patients and could care for a multitude of post-operative procedures. Additionally, this novel program can care for patients with both mild and severe systemic diseases.

Ambulatory surgery centers: A 2012 to 2018 analysis on growth in number of centers, utilization, Medicare services, and Medicare reimbursements

BACKGROUND

Given declining reimbursements and potential financial conflicts of interest in ownership, it is important to continually assess ambulatory surgery center role and growth. The objective of this study is to evaluate scope of practice, number of patients served, number of procedures performed, and revenue of ambulatory surgery centers within a Medicare fee-for-service population.

METHODS

This retrospective study includes data from Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). In addition to total number and geographic distribution, sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique current procedural terminology codes used.

RESULTS

The number of Medicare fee-for-service-serving ambulatory surgery centers grew 7.0% from 4,886 to 5,227 between 2012 and 2018. A total of 8,169,288 Medicare fee-for-service services were performed on 3,910,434 patients in 2018, an increase of 10.8% and 6.5% since 2012, respectively. At the median, each ambulatory surgery center performed 1,050 services in 2018, which was slightly less than in 2012 (median: 1,094). Ambulatory surgery centers collected $5.1 billion in payments in 2018, compared to $3.6 billion in 2012 (29.1% inflation-adjusted growth).

CONCLUSION

Total inflation-adjusted allowed Medicare fee-for-service payments have increased 29.1% between 2012 and 2018, despite just 7% growth in number of ambulatory surgery centers and 10.8% increase in total number of services. The 16.5% increase in inflation-adjusted revenue generated per service may indicate that the increased use of complex procedures with higher reimbursement, previously only performed in an inpatient setting, are now offered more readily in ambulatory surgery centers.

Joint-Venture Ambulatory Surgery Centers: The Perfect Partnership

BACKGROUND

Ambulatory surgery growth has increased in the last few decades as ambulatory surgery centers have been shown to succeed in cost efficiencies through their smaller size and breadth, specialization of care, and ability to quickly participate in perioperative process improvement and education.

METHODS

A 5-year retrospective fiscal review was performed for all Northwell Health-physician ambulatory surgery center joint ventures. The outcome measures studied included model of ownership, specialty types, and gross revenue. Additional facility characteristics were studied, including growth trajectory, facility size, and cost to build a de novo facility.

RESULTS

Eleven free-standing ambulatory surgery centers were identified at Northwell Health during the 5-year study period. The total gross revenue for all Northwell clinical joint ventures for 2019 alone was $102,854,000. Northwell Health is a majority stakeholder in eight of their joint venture ambulatory surgery centers, with an average Northwell ownership of 53 percent and an average number of physician owners per facility of 11. The number of hospital-physician joint-venture ambulatory surgery centers grew from two to 11 facilities during the study period (450 percent). Surgical volume followed a similar trajectory, increasing 295 percent over the same time period.

CONCLUSIONS

The ambulatory surgery center setting provides a vast number of possibilities for key stakeholders, including patients themselves, to benefit from financial and clinical efficiencies. Ambulatory surgery centers have been popular, as they meet patient expectations for convenience of elective surgery, reduce payer and clinical pressures to minimize length of stay in hospitals, and achieve similar or higher quality care with less intense resources.

A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion

INTRODUCTION

The movement toward reducing healthcare expenditures has led to an increased volume of outpatient anterior cervical diskectomy and fusions (ACDFs). Appropriateness for outpatient surgery can be gauged based on the duration of recovery each patient will likely need.

METHODS

Patients undergoing 1- or 2-level ACDFs were retrospectively identified at a single Level I spine surgery referral institution. Length of stay (LOS) was categorized binarily as either less than two midnights or two or more midnights. The data were split into training (80%) and test (20%) sets. Two multivariate regressions and three machine learning models were developed to predict a probability of LOS ≥ 2 based on preoperative patient characteristics. Using each model, coefficients were computed for each risk factor based on the training data set and used to create a calculatable ACDF Predictive Scoring System (APSS). Performance of each APSS was then evaluated on a subsample of the data set withheld from training. Decision curve analysis was done to evaluate benefit across probability thresholds for the best performing model.

RESULTS

In the final analysis, 1,516 patients had a LOS <2 and 643 had a LOS ≥2. Patient characteristics used for predictive modeling were American Society of Anesthesiologists score, age, body mass index, sex, procedure type, history of chronic pulmonary disease, depression, diabetes, hypertension, and hypothyroidism. The best performing APSS was modeled after a lasso regression. When applied to the withheld test data set, the APSS-lasso had an area under the curve from the receiver operating characteristic curve of 0.68, with a specificity of 0.78 and a sensitivity of 0.49. The calculated APSS scores ranged between 0 and 45 and corresponded to a probability of LOS ≥2 between 4% and 97%.

CONCLUSION

Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers

BACKGROUND

As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017.

METHODS

This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization.

RESULTS

A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South.

CONCLUSIONS

This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities

Background:

This is an updated analysis of the morbidity and mortality of cervical surgery performed in outpatient/same day (OSD) (Postoperative care unit [PACU] observation 4–6 h), and ambulatory surgicenters (ASC: PACU 23 h) versus inpatient facilities (IF).

Methods:

We analyzed 19 predominantly level III (retrospective) and IV (case series) studies regarding the morbidity/mortality of cervical surgery performed in OSC/ASC versus IF.

Results:

A “selection bias” clearly favored operating on younger/healthier patients to undergo cervical surgery in OSD/ASC centers resulting in better outcomes. Alternatively, those selected for cervical procedures to be performed in IF classically demonstrated multiple major comorbidities (i.e. advanced age, diabetes, high body mass index, severe myelopathy, smoking, 3–4 level disease, and other comorbidities) and had poorer outcomes. Further, within the typical 4–6 h. PACU “observation window,” OSD facilities “picked up” most major postoperative complications, and typically showed 0% mortality rates. Nevertheless, the author’s review of 2 wrongful death suits (i.e. prior to 2018) arising from OSD ACDF cervical surgery demonstrated that there are probably many more mortalities occurring following discharges from OSD where cervical operations are being performed that are going underreported/unreported.

Conclusion:

“Selection bias” favors choosing younger/healthier patients to undergoing cervical surgery in OSD/ ASC facilities resulting in better outcomes. Atlernatively, choosing older patients with greater comorbidities for IF surgery correlated with poorer results. Although most OSD cervical series report 0% mortality rates, a review of 2 wrongful death suits by just one neurosurgeon prior to 2018 showed there are probably many more mortalities resulting from OSD cervical surgery than have been reported.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity Between Lumbar Disc Arthroplasty Performed in the Inpatient and Outpatient Settings Utilizing the ACS-NSQIP Dataset

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings.

METHODS

Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof.

RESULTS

We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly (P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes (P < .001, OR = 7.365), baseline dyspnea (P = .039, OR = 6.447), and increased platelet count (P = .048, OR = 1.007) predicted readmission. Diabetes (P = .016, OR = 6.533) and baseline dyspnea (P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea (P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 (P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit (P = .008) and increased operative time (P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis.

CONCLUSIONS

Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.

Where Is the Value in Ambulatory Versus Inpatient Surgery?

OBJECTIVE

The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures.

SUMMARY BACKGROUND DATA

Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery.

METHODS

All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Inverse probability of treatment weighting-adjusted gamma generalized linear and logistic regression was employed to compare costs and 30-day readmission between inpatient and ambulatory-based surgery, respectively.

RESULTS

Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (P < 0.001 for all). Adjusted odds of experiencing a 30-day readmission after thyroidectomy [odds ratio (OR) 0.70, 95% confidence interval (CI), 0.53-0.93; P = 0.03], hernia repair (OR 0.28, 95% CI, 0.20-0.40; P < 0.001), and laparoscopic cholecystectomy (OR 0.37, 95% CI, 0.32-0.43; P < 0.001) were lower in the ambulatory versus inpatient setting. Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (OR 0.63, 95% CI, 0.31-1.26; P = 0.19).

CONCLUSIONS

Ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.

Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings

STUDY DESIGN

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015.

OBJECTIVE

Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings.

SUMMARY OF BACKGROUND DATA

In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge.

METHODS

The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients.

RESULTS

A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002).

CONCLUSIONS

After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration.

LEVEL OF EVIDENCE

Level III.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion

BACKGROUND

Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

RESULTS

Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

CONCLUSION

At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Men and women may be at an equivalent risk for perioperative depressive symptoms.

Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting

BACKGROUND

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.

METHODS

Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.

RESULTS

Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.

CONCLUSIONS

The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Identifying the Most Appropriate ACDF Patients for an Ambulatory Surgery Center: A Pilot Study Using Inpatient and Outpatient Hospital Data

STUDY DESIGN

Retrospective cohort analysis of prospectively collected data.

OBJECTIVES

Using a national cohort of patients undergoing elective anterior cervical discectomy and fusion (ACDF) in an inpatient/outpatient setting, the current objectives were to: (1) outline preoperative factors that were associated with complications, and (2) describe potentially catastrophic complications so that this data can help stratify the best suited patients for an ambulatory surgery center (ASC) compared with a hospital setting.

SUMMARY OF BACKGROUND DATA

ASCs are increasingly utilized for spinal procedures and represent an enormous opportunity for cost savings. However, ASCs have come under scrutiny for profit-driven motives, lack of adequate safety measures, and inability to handle complications.

METHODS

Adults who underwent ACDF between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure ACDF [Current Procedural Terminology (CPT) 22551, 22552], elective, neurological/orthopedic surgeons, length of stayof 0/1 day, and being discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications.

RESULTS

A total of 12,169 patients underwent elective ACDF with a length of stay of 0/1 day and were discharged directly home. A total of 179 (1.47%) patients experienced a complication. Multivariate logistic regression revealed the following factors were significantly associated with a complication: Charlson Comorbidity Index (CCI) >3, history of transient ischemic attack/cerebrovascular accident, abnormal bilirubin, and operative time of >2 hours. Approximate comorbidity score cutoffs associated with <2% risk of complication were: American Society of Anesthesiologists (ASA)≤2, CCI≤2, modified frailty index (mFI) ≤0.182. A total of 51 (0.4%) patients experienced potentially catastrophic complications.

CONCLUSIONS

The current results represent a preliminary, pilot analysis using inpatient/outpatient data in selecting appropriate patients for an ASC. The incidence of potentially catastrophic complication was 0.4%. These results should be validated in multi-institution studies to further optimize appropriate patient selection for ASCs.

Recent trends in medicare utilization and reimbursement for lumbar spine fusion and discectomy procedures

BACKGROUND CONTEXT

Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements.

PURPOSE

This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017.

STUDY DESIGN

Retrospective database study.

PATIENT SAMPLE

Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files.

OUTCOME MEASURES

Procedure numbers and payments per episode.

METHODS

This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements.

RESULTS

A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, -5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, -0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%).

CONCLUSIONS

This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries.

Lumbar Laminectomy in the Outpatient Setting Is Associated With Lower 30-Day Complication Rates

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare the incidence of complications in patients undergoing single-level and 2-level lumbar laminectomy in either the inpatient or outpatient settings.

METHODS

Patients who underwent single-level and 2-level lumbar laminectomy were identified in the ACS NSQIP database from the years 2006 to 2015. Independent patient variables were recorded, including demographics and preoperative health characteristics. Logistic regression was used to determine the risk of postoperative complications for both a 1- and 2-level lumbar laminectomy as well as to identify independent risk factors for a complication. Comparisons were made between 2 groups: (1) inpatient and (2) outpatient as determined by billing data.

RESULTS

A total of 18 076 single- and 2-level lumbar laminectomy cases were identified with 10 743 (59.4%) inpatient procedures and 7333 (40.6%) outpatient procedures. The incidence of any postoperative complication was significantly lower in the outpatient group than in the inpatient group among all cohorts including 1-level lumbar laminectomy (1.9% vs 6.7%), 2-level lumbar laminectomy (3.17% vs 7.38%), as well as in the combined cohort of 1- and 2-level laminectomies (2.47% vs 7.01%). Significant independent risk factors for complications after lumbar laminectomy were identified, including body mass index (BMI) >30 kg/m², age ≥55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time >90 minutes.

CONCLUSIONS

This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included BMI >30 kg/m², age ≥55 years, a functional status of partially dependent, COPD, chronic steroid use, ASA class 3 or 4, and operative time >90 minutes.

Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department-an analysis of 90-day outcomes and costs

BACKGROUND CONTEXT

While free-standing ambulatory surgical centers (ASCs) have been extolled as lower cost settings than hospital outpatient facilities/departments (HOPDs) for performing routine elective spine surgeries, differences in 90-day costs and complications have yet to be compared between the two types of treatment facilities.

PURPOSE

We carried a comprehensive analysis to report the differences on payments to providers and facilities as a reflection of true costs to patients, employers and health plans for patients undergoing primary, single-level lumbar microdiscectomy/decompression at ASC versus HOPD.

STUDY DESIGN

Retrospective review of Medicare advantage and commercially insured enrollees from the Humana dataset from 2007 to 2017Q1.

OUTCOME MEASURES

To understand the differences in 90-day complications, readmissions, emergency department visits and costs for patients undergoing primary, single-level lumbar microdiscectomy/decompressions at an ASC versus HOPD.

METHODS

The Humana 2007 to 2017Q1 was queried using Current Procedural Terminology codes to identify patients undergoing primary, single-level lumbar microdiscectomy/decompressions. Patients undergoing two-level surgery, open laminectomies, fusions, revision discectomies, and/or deformities were excluded. Service Location codes for HOPD (Location Code 22) and free-standing ASC (Location Code 24) were used to determine surgery treatment facilities. Using propensity scoring, we matched two groups who had surgery performed in ASCs or HOPDs based on age, gender, race, region and Elixhauser comorbidity index. Multivariable logistic regression analyses were performed on matched cohorts to assess for differences in 90-day outcomes between facilities, while controlling for age, gender, race, region, plan, and Elixhauser comorbidity index.

RESULTS

A total of 1,077 and 10,475 primary single-level decompressions were performed in ASCs and HOPDs, respectively. Following a matching algorithm with propensity scoring, the two cohorts were comprised of 990 patients each. Observed differences in 90-day complication rates were not statistically or clinically significant (ASC=9.1% vs. HOPD=10.3%; p=.362) nor were readmissions (ASC=4.5% vs. HOPD=5.3%; p=.466). On average, performing surgery in an ASC versus HOPD resulted in significant cost savings of over $2,000/case in Medicare Advantage ($5,814 vs. $7,829) and over $3,500/case ($10,116 vs. $13,623) in commercial beneficiaries.

CONCLUSION

Performing single-level decompression surgeries in an ASC compared with HOPDs was associated with approximately $2,000 to $3,500 cost-savings per case with no statistically significant impact on complication or readmission rates.

Scientific View on Endoscopic Spine Surgery: Can Spinal Endoscopy Become a Mainstream Surgical Tool?

With the health care environment becoming increasingly patient centric and cost-conscious, interest levels in spinal endoscopy are at an all-time high. Patient demand for the least invasive procedures combined with surgeon desire to maximally shorten the postoperative recovery period has further driven this surgical evolution. Mounting scientific evidence demonstrates the noninferiority and perhaps even superiority of endoscopic techniques to more conventional spinal surgery for the treatment of spinal stenosis and disc herniations. Although higher level evidence is much needed to support the clinical utility of the latest endoscopic techniques and surgical indications, it appears that the entrance of spinal endoscopy into the mainstream arena of spinal surgery is inevitable.

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BACKGROUND

The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs.

AIM

To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries.

METHODS

A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared.

MAIN OUTCOME MEASURE

The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups.

RESULTS

A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial.

CLINICAL IMPLICATIONS

IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer.

STRENGTHS & LIMITATIONS

The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding.

CONCLUSION

ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

Outcomes and value in elective cervical spine surgery: an introductory and practical narrative review

How we determine a successful clinical outcome and the value of a spine intervention are two major questions surrounding clinical spine research. Patient-reported outcomes (PROs), both LEGACY and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, are becoming ubiquitous throughout the literature. Spine surgeons need a facile understanding of the financial landscape of their environment to influence change. In the current introductory, narrative review on outcomes and value in cervical spine surgery, we aim to: (I) define relevant outcome and cost terminology, (II) review recent cervical spine surgery literature, divided by specific pathology with a focus on LEGACY and PROMIS measures, and (III) discuss value and cost as they pertain to postoperative return to work and ambulatory surgery centers surgeries.

Trends in National Use of Anterior Cervical Discectomy and Fusion from 2006 to 2016

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) is the most common procedure for the treatment of degenerative cervical conditions. The objective of this study is to determine time-dependent trends in patient outcomes following ACDF for degenerative disease from 2006 to 2016.

METHODS

We used the National Surgical Quality Improvement Program (NSQIP) database to retrospectively review all patients who underwent elective ACDF between 2006 and 2016. A descriptive statistical analysis followed by time trend analysis was performed on demographics, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission rates. Secondary outcomes were medical and surgical complications reported within 30 days of operation.

RESULTS

A total of 36,854 patients underwent elective ACDF from the 2006 to 2016 NSQIP database. Mean age increased from 48.19 years [standard error: 1.49] in 2006 to 54.08 years [standard error: 0.12] in 2016 (P < 0.001). There was a significantly greater number of outpatient procedures from 2012 to 2016 (P < 0.001). The proportion of patients with American Society of Anesthesiologists classes 3/4 significantly increased over time (P < 0.001, P < 0.001, P = 0.005, respectively). Readmission risk, first documented in NSQIP in 2011, increased over time from 2011 to 2016 (P < 0.001). Unplanned reoperations have remained consistent at about 1.4%. Postoperative complications varied over time with no discernable patterns or trends.

CONCLUSIONS

Since the establishment of the NSQIP database, there have been no considerable improvements in reoperation or postoperative complication rates based on available data, however, there have been increased rates of readmission. Changes in data collection and an aging patient population with greater burden of comorbidities could confound these trends.

Early outcomes and safety of outpatient (surgery center) vs inpatient based L5-S1 Anterior Lumbar Interbody Fusion

We seek to determine the outcomes of patients undergoing outpatient-based ALIF compared to a consecutive series of inpatient based ALIF performed during the same time period. 58 consecutive patients at a single outpatient surgery center underwent ALIF from June 2015 - August 2017 and 79 ALIF's were performed at 2 Inpatient hospitals. Electronic medical records were reviewed for perioperative and postoperative complications as well as secondary interventions. 62 patients met inclusion criteria (29 Outpatient, 33 Inpatient). The inpatient group was significantly older (44 vs 51; p = 0.01). There were 8 postoperative complications. There was no difference in secondary interventions; 28 patients underwent a total of 36 interventions postoperatively for pain. Secondary interventions were performed at an average of 128(outpatient) and 158(inpatient) days (p = 0.55). There was no difference in outcome scores between the inpatient/outpatient groups at any time. Patients receiving a secondary intervention showed no significant improvement in Back VAS scores but, demonstrated a strong trend (p = 0.06) towards leg pain improvement. Patients who did not undergo secondary intervention had significant improvement in both Back and Leg VAS scores at all time points (p < 0.05). Outpatient ALIF is a safe and reproducible procedure with complication rates consistent with or lower than published rates. Patients outcome scores were no different in the inpatient versus outpatient group. Interestingly, there was a high number of secondary interventions performed in both groups. Patients undergoing a secondary procedure did not get statistically significant improvement in Back VAS but, demonstrated a strong trend in Leg VAS patient reported outcome scores.

US Trends of Opioid-use Disorders and Associated Factors Among Hospitalized Patients With Spinal Conditions and Treatment From 2005 to 2014

STUDY DESIGN

Serial cross-sectional study utilizing the National Inpatient Sample (NIS) 2005 to 2014.

OBJECTIVE

The aim of this study was to examine the trends of opioid-use disorders among hospitalized patients with spinal conditions and treatment and to identify its contributing factors.

SUMMARY OF BACKGROUND DATA

The opioid is widely used in chronic spinal conditions, and misuse of prescriptions is the main culprit of the opioid crisis. Cannabis, the most commonly utilized illicit drug, has recently been substituted for opioid despite increasing cannabis-use emergency room visits. There is limited information on opioid-use disorders, the association with cannabis, and other contributing factors.

METHODS

We analyzed the 2005 to 2014 NIS data that identified opioid-use disorders among hospitalized patients with cervical and lumbar spinal conditions and treatment using the International Classification of Disease, Ninth Revision-Clinical Modification codes for opioid abuse, dependence, poisoning, and cervical and lumbar spinal diseases and procedures. The compound annual growth rate (CAGR) was used to quantify trends of opioid-use disorders among hospitalized patients. Multilevel and multivariable regression analyses were performed to determine their contributing factors.

RESULTS

The number of hospitalizations with spinal conditions and treatment increased from 2005 to 2011, then decreased between 2011 and 2014 with an overall decrease in length of stay, resulting in the CAGR of -1.60% (P < .001). Almost 3% (2.93%, n = 557,423) of hospitalized patients with spinal conditions and treatment were diagnosed as opioid-use disorders and its CAGR was 6.47% (P < .0001). Opioid-use disorders were associated with cannabis-use disorders (odds ratio 1.714), substance use, mental health condition, younger age, white race, male sex, higher household income, and public insurance or uninsured.

CONCLUSION

This study suggests that opioid-use disorders are increasing among hospitalized patients with spinal conditions and treatment and associated with several demographic, and socioeconomic factors, including cannabis-use disorders.

LEVEL OF EVIDENCE

3.

Ambulatory Surgical Centers: Improving Quality of Operative Spine Care?

STUDY DESIGN

Narrative review with commentary.

OBJECTIVE

Present healthcare reform focuses on cost-optimization and quality improvement. Spine surgery has garnered particular attention; owing to its costly nature. Ambulatory Surgical Centers (ASC) present a potential avenue for expenditure reduction. While the economic advantage of ASCs is being defined, cost saving should not come at the expense of quality or safety.

METHODS

This narrative review focuses on current definitions, regulations, and recent medical literature pertinent to spinal surgery in the ASC setting.

RESULTS

The past decade witnessed a substantial rise in the proportion of certain spinal surgeries performed at ASCs. This setting is attractive from the payer perspective as remuneration rates are generally less than for equivalent hospital-based procedures. Opportunity for physician ownership and increased surgeon productivity afforded by more specialized centers make ASCs attractive from the provider perspective as well. These factors serve as extrinsic motivators which may optimize and improve quality of surgical care. Much data supports the safety of spine surgery in the ASC setting. However, health care providers and policy makers must recognize that current regulations regarding safety and quality are less than comprehensive and the data is predominately from selected case-series or comparative cohorts with inherent biases, along with ambiguities in the definition of "outpatient."

CONCLUSIONS

ASCs hold promise for providing safe and efficient surgical management of spinal conditions; however, as more procedures shift from the hospital to the ASC rigorous quality and safety data collection is needed to define patient appropriateness and track variability in quality-related outcomes.

No S.C.A.R.E. Protocol: A Streamlined Safety Protocol

INTRODUCTION

Despite the proven success of anterior cervical surgery (ACS) postoperative issues can arise, with retropharyngeal hematoma (RH) being one of the most feared. A recent USA Today article highlighted the failed management and subsequent death of patients developing RH after ACS. The article calls into question the safety of performing ACS in an outpatient setting.

METHODS

We tested the knowledge of 20 healthcare professionals (4 surgeons, 16 ancillary providers) regarding ways to minimize the post-ACS complications. We used a multiple-choice and fill-in-the-blank test. We then developed a No S.C.A.R.E. safety protocol and after teaching the same professionals, re-administered the examination to assess improvement.

RESULTS

We identified large gaps in knowledge between spine surgeons and other providers (92.3% versus 31.2%) on preintervention testing. Postintervention testing showed significant improvement in nonsurgeon scores (31.2% to 86.1%, P < 0.01). Improvement was also seen in provider confidence after completion of the education module.

CONCLUSION

Previous studies demonstrate that the incidence of RH necessitating evacuation after ACS is extremely small (<1%). For rare complications, healthcare teams may benefit from educational modules and standardized protocols. After implementation of our No S.C.A.R.E. protocol, provider knowledge and confidence markedly improved. We recommend similar education modules and protocols be used at other institutions performing ACS.

Identifying the most appropriate lumbar decompression patients for ambulatory surgery centers - A pilot study using inpatient and outpatient hospital data

INTRODUCTION

To minimize healthcare related costs, ambulatory surgery centers (ASCs) have become increasingly favored venues for outpatient spine surgery. Using a national cohort of patients undergoing elective lumbar decompression (LD) in an inpatient or outpatient hospital setting, the current objectives were to: 1) outline specific factors that were associated with complications, and 2) describe potentially catastrophic complications.

METHODS

Adults who underwent LD between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure LD (CPT 63030), elective, neurologic/orthopaedic surgeons, length of stay (LOS) of 0/1 days, and discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. Univariate/multivariable logistic regression was performed.

RESULTS

A total of 19,908 patients met the inclusion criteria. 564 (2.83%) patients experienced a complication. Cardiac intervention remained the only independent predictor of complications after multivariate testing (OR: 2.02, 95% CI: 1.00, 4.07, p = 0.049). Approximate comorbidity score cut-offs associated with <2% risk of complication were: ASA ≤ 3, CCI ≤ 5, mFI ≤ 0.182. A total of 96 (0.48%) patients experienced potentially catastrophic complications.

CONCLUSIONS

We utilized a national cohort of patients undergoing elective inpatient and outpatient LD in a hospital setting to identify preoperative risk factors for postoperative complications. Previous cardiac intervention was the sole independent predictor of complications. Although no patients treated at ASCs were studied, we believe these factors can aid in selecting patients most appropriate for ASCs and begin the process of selecting the best patients for an ambulatory setting.

Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases

BACKGROUND

In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety.

OBJECTIVE

To analyze 2000 ASC-ACDF cases, describe patient selection and perioperative protocol, and report associated safety profile.

METHODS

A total of 2000 patients who underwent 1 to 3 level ACDF in a single ASC from 2006 to 2018 were included in this retrospective analysis. Patients were observed in a 4-h postanesthesia care unit (PACU) with a multimodal pain management regiment. Data were collected on patient demographics, comorbidities, operative details, and 30- and 90-d morbidity.

RESULTS

Of the 2000 patients, 10 (0.5%) required transfer to an inpatient setting within the 4-h observation. Reasons for transfer included hematoma (2), pain control (2), cerebrospinal fluid leak (1), and medical complications (5). Six patients (0.3%) underwent reoperation within 30 d. All-cause 30-d readmission was 1.9%.

CONCLUSION

An analysis of 2000 ACDF patients in an ASC setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (&lt;1%) and can be appropriately diagnosed and managed in a 4-h PACU. In an effort to decrease healthcare costs, surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here.

Comparison of Multilevel Anterior Cervical Discectomy and Fusion Performed in an Inpatient Versus Outpatient Setting

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate differences in patient factors, procedural factors, early outcomes and safety in mutlilevel anterior cervical discectomy and fusion (ACDF) in the inpatient versus outpatient setting.

METHODS

Patient demographics, operative factors, and outcomes of multilevel ACDF performed in an inpatient and outpatient setting were compared using Fisher's exact test for categorical and Student's t test for continuous variables.

RESULTS

Fifty-seven patients had surgery on an outpatient and 46 on an inpatient basis. Inpatients were older (56.7 vs 52.2 years, P = .012) and had a higher ASA (American Society of Anesthesiologists) class (P = .002). Sixty percent of 2-level cases were outpatient surgeries, compared with 35% of 3-level cases (P = .042). Outpatients had shorter operative times (71.26 vs 83.59 minutes, P < .0001) and shorter lengths of stay (8.51 vs 35.76 hours, P < .0001), lower blood loss (33.04 vs 45.87 mL, P = .003), and fewer in-hospital complications (5.3% vs 37.0%, P < .0001). Outpatients had better early outcomes in terms of 6-week Neck Disability Index (NDI) (27.97 vs 37.59, P = .014), visual analogue scale (VAS) neck (2.92 vs 4.02, P = .044), and Short Form-12 Physical Health Score (SF-12 PHS) (35.66 vs 30.79, P = .008). However, these differences did not persist at 6 months.

CONCLUSIONS

The results of our study suggest that multilevel ACDF can be performed safely in the outpatient setting without an increased risk of complications compared with the inpatient setting in an appropriately selected patient. Specifically, patients' age, ASA class, and number of levels being fused should be taken into consideration. At our institution, ASA class 3, body mass index >40 kg/m², age >80 years, intubation time >2.5 hours, or not having a responsible adult with the patient warrant inpatient admission. Importantly, the setting of the surgery does not affect patient-reported outcomes.

Minimally invasive lumbar decompression in an ambulatory surgery center

Background

There is limited data regarding clinical and surgical outcomes of minimally invasive lumbar decompression (MIS LD) as an outpatient procedure. In this context, our purpose is to evaluate a single surgeon's experience with performing MIS LD in the outpatient versus inpatient setting and determining if there are differences in surgical and clinical outcomes.

Methods

Patients undergoing primary, one- to three-level MIS LD were retrospectively reviewed and stratified by surgical setting: ambulatory surgical center (ASC) versus hospital. The cohorts were compared with respect to demographics, perioperative characteristics, complications, postoperative pain and narcotics consumption, and improvements in patient-reported outcomes.

Results

Five hundred and nine patients were included: 332 patients underwent surgery at an ASC and 177 patients underwent surgery at a hospital. The ASC patients were younger, more likely to be male, and carry Workers' Compensation insurance. The hospital patients were older, more likely to be diabetic, and had a greater comorbidity burden. Patients undergoing MIS LD in an ASC were less likely to have multi-level procedures and more likely to have decompression with discectomy compared to patients in the hospital cohort. There were two cases of superficial wound infection in the ASC cohort and a single case of a pulmonary embolus in the hospital cohort. Additionally, a total of 28 patients had recurrent herniated nucleus pulposus in the ASC cohort compared to 12 patients in the hospital cohort. There was one case of residual stenosis in the ASC cohort compared to eight cases in the hospital cohort. Both cohorts demonstrated similar preoperative ODI, VAS back pain, and VAS leg pain scores through 12-month follow-up.

Conclusions

MIS LD is a safe and effective procedure in an ASC, however, appropriate patient selection and postoperative protocols are imperative in minimizing complications and optimizing safety and efficacy in the outpatient setting.

Spine centers of excellence: applications for the ambulatory care setting

Centers of excellence (COE) are designed to deliver high-quality, cost-effective healthcare by providing specialized and comprehensive multidisciplinary care for a given condition and have become attractive option to both insurers and healthcare providers given their promise of creating value. The criteria that constitute and define a COE may be delineated by a number of entities with a stake in value-based healthcare delivery including professional societies, the federal government, insurers and businesses seeking to control costs while guaranteeing outcomes for their employees. COEs accomplish this goal through a number of means, the first and most essential of which is centralization of organization wherein a variety of specialists are integrated under a single hospital system to improve communication between providers and decrease overall variability of care delivery. In this system, the patient is tracked throughout the entire spectrum of care from diagnosis, through non-operative or surgical intervention, and postoperative care. The centralized model in turn allows for standardization of protocols and multidisciplinary team input which helps to inform case selection, improve patient screening, make treatment more uniform and ultimately allow for dynamic and continual modification of best practices. This model lends itself particularly well to orthopedic subspecialties where patients often require specialized pre-, intra- and post-operative care from a variety of providers. However, despite their apparent benefits, studies evaluating outcomes after implementation of COEs have been less than favorable, and further research is needed in this area to support their widespread adoption. The growth of the ambulatory surgery center in orthopedics provides a new opportunity for the development, evaluation and evolution of spine COEs. Although the direct value of COEs is yet to be firmly established, they provide guidelines for best practices in outpatient spine surgery and a framework for how spine care can be transitioned safely and effectively to the outpatient setting.