Long-run growth of ambulatory surgery centers 1990-2015 and Medicare payment policy

Hospital behavior over the private equity life cycle

Private equity is an increasing presence in US healthcare, with unclear consequences. Leveraging unique data sources and difference-in-differences designs, we examine the largest private equity hospital takeover in history. The affected hospital chain sharply shifts its advertising strategy and pursues joint ventures with ambulatory surgery centers. Inpatient throughput is increased by allowing more patient transfers, and crucially, capturing more patients through the emergency department. The hospitals also manage shorter, less treatment-intensive stays for admitted patients. Outpatient surgical care volume declines, but remaining cases focus on higher complexity procedures. Importantly, behavior changes persist even after private equity divests.

The Impact of Pediatric Laparoscopic Inguinal Hernia Repair in a Community Based Children's Ambulatory Surgery Center - It's Safe and Effective

PURPOSE

Pediatric surgery in a free-standing children's ambulatory surgery center (C-ASC) is a common practice. The implementation of minimally invasive surgery in this setting may be associated with unique challenges. The purpose of this study was to compare a cohort of children who underwent laparoscopic (LHR) and open inguinal hernia repairs (OHR) at the C-ASC as part of a quality assurance initiative to assess safety and efficacy.

METHODS

From January 2021 to December 2021, the records of all children who underwent LHR or OHR at our C-ASC were analyzed. The following data was retrieved and compared with the Student's t-test: age, weight, gender, procedure type, total room time (RT), total operative time (OT), and outcomes.

RESULTS

Eighty-eight (n = 88) children underwent LHR or OHR during this period. There was no difference between the two groups regarding their age or weight. Both groups had equal outcomes, specifically, no wound infections or recurrent hernias. (2.5 year follow-up). There was a significant reduction in RT and OT in those children who underwent unilateral LHR compared to unilateral OHR (15% and 17% respectively, p < 0.05). In those children who underwent bilateral LHR and bilateral OHR, there was a reduction in RT and OT in the LHR group compared to OHR, but it was not significant (10% and 12% respectively, p > 0.05).

CONCLUSIONS

Pediatric LHR is safe and effective in the C-ASC. The unilateral LHR technique is associated with a significant reduction in total room time and operative time compared to the unilateral OHR technique. Additional analyses would be important to examine the relationship of time and outcomes in this setting.

TYPE OF STUDY

Original Research Retrospective Case-control study.

Cerebral angiography in outpatient endovascular centers: roadmap and lessons learned from interventional radiology, cardiology, and vascular surgery

A growing proportion of percutaneous procedures are performed in outpatient centers. The shift from hospitals to ambulatory surgery centers and office-based laboratories has been driven by a number of factors, including declining reimbursements, increased patient demand, and competition for hospital resources. This transition has been dominated by the interventional radiology, cardiology, and vascular surgery fields. Cerebral angiography, in contrast, is still performed almost exclusively in a hospital-based setting, despite sharing many features with other endovascular procedures commonly performed in outpatient centers. As interest grows in performing cerebral angiography in outpatient endovascular centers, much can be learned from the decades of experience that our interventional colleagues have in the outpatient setting. In this article we examine the outpatient experience of other interventional fields and apply key principles to evaluate the prospect of outpatient neurointervention. The literature suggests that cerebral angiography can feasibly be performed in an outpatient center in both private and academic settings, as some groups have begun to do. Outpatient endovascular centers have helped to improve the patient experience, liberate inpatient resources, and control costs in other interventional fields, and might offer neurointerventionalists an opportunity to do the same.

Development and validation of an instrument to predict prolonged length of stay in the postanesthesia care unit following ambulatory surgery

PURPOSE

We sought to develop and validate an Anticipated Surveillance Requirement Prediction Instrument (ASRI) for prediction of prolonged postanesthesia care unit length of stay (PACU-LOS, more than four hours) after ambulatory surgery.

METHODS

We analyzed hospital registry data from patients who received anesthesia care in ambulatory surgery centres (ASCs) of university-affiliated hospital networks in New York, USA (development and internal validation cohort [n = 183,711]) and Massachusetts, USA (validation cohort [n = 148,105]). We used stepwise backwards elimination to create ASRI.

RESULTS

The model showed discriminatory ability in the development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI], 0.82 to 0.83), 0.82 (95% CI, 0.81 to 0.83), and 0.80 (95% CI, 0.79 to 0.80), respectively. In cases started in the afternoon, ASRI scores ≥ 43 had a total predicted risk for PACU stay past 8 p.m. of 32% (95% CI, 31.1 to 33.3) vs 8% (95% CI, 7.9 to 8.5) compared with low score values (P-for-interaction < 0.001), which translated to a higher direct PACU cost of care of USD 207 (95% CI, 194 to 2,019; model estimate, 1.68; 95% CI, 1.64 to 1.73; P < 0.001) The effects of using the ASRI score on PACU use efficiency were greater in a free-standing ASC with no limitations on PACU bed availability.

CONCLUSION

We developed and validated a preoperative prediction tool for prolonged PACU-LOS after ambulatory surgery that can be used to guide scheduling in ambulatory surgery to optimize PACU use during normal work hours, particularly in settings without limitation of PACU bed availability.

Private equity and healthcare firm behavior: Evidence from ambulatory surgery centers

Healthcare firms regularly seek outside capital; yet, we have an incomplete understanding of external investor influence on provider behavior. We investigate the effects of private equity investment, divestment, and an initial public offering (IPO) on ambulatory surgery centers (ASCs). Throughput is unchanged while charges grow by up to 50% for the same service mix. Affected ASCs witness declines in privately insured cases and rely more on Medicare business. Private equity increases physician ASC ownership stakes, and both simultaneously divest when the ASC is sold. Our findings appear more consistent with private equity influencing the financing of ASCs, rather than treatment approaches.

Peripheral Arterial Disease Treatment in the Non-Hospital Setting

Treatment of peripheral artery disease (PAD) has undergone a progressive shift toward less invasive, endovascular options within the last three decades. For PAD patients, the benefits of this shift are numerous and include less periprocedural pain, decreased blood loss, shorter recovery times, and fewer missed workdays. Commonly, patient-reported outcomes are very positive with this "endovascular first" strategy and the number of open surgical procedures for various stages of PAD has declined steadily over the last 20 years. Coincident with this trend is the move toward "ambulatory" lower extremity arterial intervention (LEAI) in the hospital outpatient "same-day" department. The next logical extension was then performing LEAI in a true physician office-based lab (OBL), ambulatory surgical center (ASC), or "non-hospital setting." This article examines these trends and the concept that the OBL/ASC provides a safe, alternative site of service for PAD patients requiring LEAI.

Expected changes in physician outpatient interventional practices as a result of coronavirus disease 2019 and recent changes in Medicare physician fee schedule

OBJECTIVE

We examined the economic and practice effects of the coronavirus disease 2019 (COVID-19) pandemic and decreased Medicare physician payments on outpatient vascular interventional procedures.

METHODS

A 21-point survey was constructed and sent electronically to the physician members of the Outpatient Endovascular and Interventional Society and the American Vein and Lymphatic Society. The survey responses were converted to a Likert scale and statistical analyses performed to examine the associations between the response variables and the characteristics and practice patterns of the physician respondents.

RESULTS

A total of 165 physicians responded to the survey, of whom 33% were vascular surgeons, 18% were radiologists, and 15% were general surgeons. For slightly more than one half (55%), their interventional practice was limited to the office setting, with the remainder also performing procedures in an office-based laboratory (OBL), ambulatory surgery center (ASC), or hospital. Almost all respondents had performed superficial venous interventions, with slightly more than one third also performing either deep venous procedures and/or peripheral arterial interventions. The COVID-19 pandemic had affected 98% of the practices, with a staff shortage reported by 63%. The most-established physicians, those with the longest interval since training completion, were the least likely to have experienced staff shortages. Almost all (94%) the respondents expected that the recent Medicare payment changes will have a negative effect on their practice. Physicians with only an office-based practice were less likely to add a physician associate compared with those with an OBL (P = .036). More than one quarter reported that it was likely they would close or sell their interventional practice in the next 2 years and 43% reported they were planning to retire early. The anticipated ameliorative responses to the decreased Medicare physician payments included adding wound care (24%) or other clinical services (36%) to their practices, with the alternatives considered more by younger physicians (P = .002) and nonsurgeons (P = .047). Only 10% expected to convert their practices to an ASC or hybrid ASC/OBL (16%).

CONCLUSIONS

The emotional and economic effects of the COVID-19 pandemic and the decreased Medicare physician reimbursement rates for vascular outpatient interventionalists have been significant. Even greater challenges for the financial viability of office practices and OBLs can be expected in the near future if additional further planned cuts are put into effect.

The impact of hypoalbuminemia on postoperative outcomes after outpatient surgery: a national analysis of the NSQIP database

PURPOSE

Hypoalbuminemia has been described as a modifiable factor to optimize postoperative outcomes after major inpatient surgeries. Nevertheless, the role of hypoalbuminemia on outpatient procedures is not well defined. The purpose of this study was to examine the impact of hypoalbuminemia on postoperative outcomes of patients undergoing low-risk outpatient surgery.

METHODS

Patients were extracted from the American College of Surgeons National Surgical Quality Improvement Program database who had outpatient surgery from 2018 and recorded preoperative albumin levels. The primary outcome was a composite of any major complications including: 1) unplanned intubation, 2) pulmonary embolism, 3) ventilator use > 48 hr, 4) progressive renal failure, 5) acute renal failure, 6) stroke/cerebrovascular accident, 7) cardiac arrest, 8) myocardial infarction, 9) sepsis, 10) septic shock, 11) deep venous thrombosis, and 12) transfusion. Death, any infection, and readmissions were secondary outcomes.

RESULTS

A total of 65,192 (21%) surgical outpatients had albumin collected preoperatively and 3,704 (1.2%) patients had levels below 3.5 g⋅dL-1. In the albumin cohort, 394/65,192 (0.6%) patients had a major medical complication and 68/65,192 (0.1%) patients died within 30 days after surgery. Albumin values < 3.5 g⋅dL-1 were associated with major complications (adjusted odds ratio [aOR], 1.92; 95% confidence interval [CI], 1.44 to 2.57; P < 0.001; death-adjusted OR, 3.03; 95% CI, 1.72 to 5.34; P < 0.001); any infection (aOR, 1.49; 95% CI, 1.23 to 1.82; P < 0.001); and readmissions (aOR, 1.82; 95% CI, 1.56 to 2.14; P < 0.001). In addition, when evaluated as a continuous variable in a multivariate analysis, for each increase in albumin of 0.10 g⋅dL-1, there was an associated reduction of major complications (aOR, 0.94; 95% CI, 0.92 to 0.96; P < 0.001).

CONCLUSIONS

Hypoalbuminemia is associated with major complications and death in outpatient surgery. Since hypoalbuminemia is a potential modifiable intervention, future clinical trials to evaluate the impact of optimizing preoperative albumin levels before outpatient surgery are warranted.

Evaluation of Regional Geospatial Clusters in Inguinal Hernia Repair

Introduction

There is significant variation in how inguinal hernia repairs are conducted across the United States (US). This study seeks to utilize national public data on inguinal hernia repair to determine regional differences in the use of ambulatory surgical centers (ASC) and in the choice of laparoscopic or open technique.

Methods

Medicare provider billing and enrollee demographic data were merged with US census and economic data to create a county-level database for the years 2014-2019. Location, technique, and total count of all inguinal hernia repair billing were recorded for 1286 counties. Moran’s I cluster analysis for inguinal hernia repairs, percent laparoscopic technique, and percent ACS were conducted. Subsequent hotspot and coldspot clusters identified in geospatial analysis were compared using ANOVA across 50 socioeconomic variables with a significance threshold of 0.001. 

Results 

There were 292,870 inguinal hernia repairs, of which 39.8% were conducted laparoscopically and 21.3% of which were in an ACS. Inguinal hernia repair coldspots were in the Mid-Atlantic and Northern Midwest, while hotspots were in Nebraska, Kansas, and Maryland (3.85 and 36.53 repairs per 1000 beneficiaries, respectively). Compared to coldspots, hotspot areas of repair were less obese, had less tobacco use, older, and less insured; there were no differences in gender, white population, or county urbanization (p<0.001). Laparoscopic technique coldspots were in the Mid-Atlantic, Michigan, and Great Plains, while hotspots were in the Rocky Mountains and contiguous states from Florida to Wisconsin (6.14% and 75.39%, respectively). ACS coldspots were diffusely scattered between Oklahoma and New Hampshire, while hotspots were in California, Colorado, Maryland, Tennessee, and Indiana (0.51% and 48.71%, respectively).

Conclusions

Inguinal hernia repair, the surgical setting, and the choice of technique demonstrated interesting geospatial trends in our population of interest that have not been previously characterized.