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Im J, Soliman MAR, Quiceno E, Elbayomy AM, Aguirre AO, Kuo CC, Sood EM, Khan A, Levy HW, Ghannam MM, Pollina J, Mullin JP. Comparative analysis of patient demographics, perioperative outcomes, and adverse events after lumbar spinal fusion between urban and rural hospitals: an analysis of the National Inpatient Sample (NIS) database. Clin Neurol Neurosurg 2024; 243:108375. [PMID: 38901378 DOI: 10.1016/j.clineuro.2024.108375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Rural location of a patient's primary residence has been associated with worse clinical and surgical outcomes due to limited resource availability in these parts of the US. However, there is a paucity of literature investigating the effect that a rural hospital location may have on these outcomes specific to lumbar spine fusions. METHODS Using the National Inpatient Sample (NIS) database, we identified all patients who underwent primary lumbar spinal fusion in the years between 2009 and 2020. Patients were separated according to whether the operative hospital was considered rural or urban. Univariable and multivariable regression models were used for data analysis. RESULTS Of 2,863,816 patients identified, 120,298 (4.2 %) had their operation at a rural hospital, with the remaining in an urban hospital. Patients in the urban cohort were younger (P < .001), more likely to have private insurance (39.81 % vs 31.95 %, P < .001), and fewer of them were in the first (22.52 % vs 43.00 %, P < .001) and second (25.96 % vs 38.90 %, P < .001) quartiles of median household income compared to the rural cohort. The urban cohort had significantly increased rates of respiratory (4.49 % vs 3.37 %), urinary (5.25 % vs 4.15 %), infectious (0.49 % vs 0.32 %), venous thrombotic (0.57 % vs 0.24 %, P < .001), and neurological (0.79 % vs 0.36 %) (all P < .001) perioperative complications. On multivariable analysis, the urban cohort had significantly increased odds of the same perioperative complications: respiratory (odds ratio[OR] = 1.48; 95 % confidence interval [CI], 1.26-1.74), urinary (OR = 1.34; 95 %CI, 1.20-1.50), infection (OR = 1.63; 95 %CI, 1.23-2.17), venous thrombotic (OR = 1.79; 95 %CI, 1.32-2.41), neurological injury (OR = 1.92; 95 %CI, 1.46-2.53), and localized infection (OR = 1.65; 95 %CI, 1.25-2.17) (all P < .001). CONCLUSIONS Patients undergoing lumbar fusions experience significantly different outcomes based on the rural or urban location of the operative hospital.
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Affiliation(s)
- Justin Im
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA; Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ahmed M Elbayomy
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Evan M Sood
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Hannon W Levy
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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Tropf JG, Hoyt BW, Nelson SY, Rabin SE, Tucker CJ. Effect of surgery setting for outpatient shoulder procedures on early postoperative complications in a military population. J Shoulder Elbow Surg 2024:S1058-2746(24)00427-0. [PMID: 38908467 DOI: 10.1016/j.jse.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND There has been a recent push to transition procedures previously performed at hospital-based outpatient surgical departments (HOPDs) to ambulatory surgery centers (ASCs). However, limited data regarding differences in early postoperative complications and care utilization (eg, emergency department visits and unplanned admissions) may drive increased overall costs or worse outcomes. PURPOSE/HYPOTHESIS The purpose of this study was to examine differences in early 90-day adverse outcomes and postoperative emergency department visits associated with shoulder surgeries excluding arthroplasties that were performed in HOPDs and ASCs in a closed military health care system. We hypothesized that there would be no difference in outcomes between treatment settings. METHODS We retrospectively evaluated the records for 1748 elective shoulder surgeries from 2015 to 2020. Patients were considered as 1 of 2 cohorts depending on whether they underwent surgery in an ASC or HOPD setting. We evaluated groups for differences incomplexity, surgical time, and medical risk. Outcome measures were emergency department visits, unplanned hospital admissions, and complications within the first 90 days after surgery. RESULTS There was no difference in 90-day postoperative emergency department visits between procedures performed at HOPDs (n = 606) and ASCs (n = 1142). There was a slight increase in rate of unplanned hospital admission within 90 days after surgery in the HOPD cohort, most commonly for pain or overnight observation. The surgical time was significantly shorter (105 vs. 119 minutes, P < .01) at the ASC, but there was no difference in case complexity between the cohorts (P = .28). DISCUSSION/CONCLUSION Our results suggest that in appropriate patients, surgery in ASCs can be safely leveraged for its costs savings, efficiency, patient satisfaction, decreases in operative time, and potentially decreased resource utilization both during surgery and in the early postoperative period.
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Affiliation(s)
- Jordan G Tropf
- Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Benjamin W Hoyt
- Department of Orthopedic Surgery, James A Lovell Federal Health Care Center, North Chicago, IL, USA
| | - Sarah Y Nelson
- Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Sarah E Rabin
- Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher J Tucker
- Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD, USA
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Lewandrowski KU, Alhammoud A, Schlesinger SM, Gelber BR, Gerber MB, Lorio M. Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey. Int J Spine Surg 2024; 18:199-206. [PMID: 38664036 PMCID: PMC11287806 DOI: 10.14444/8596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. METHODS A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. RESULTS The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. CONCLUSION Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. CLINICAL RELEVANCE ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Division Personalized Pain Research and Education, Center For Advanced Spine Care of Southern Arizona, Tucson, AZ, USA
- Department Orthopaedic Surgery, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
- Department of Orthopaedic Surgery, Doctor honoris causa, Hospital Universitário Gaffree Guinle Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Brazilian National Academy of Medicine, Rio de Janeiro, RJ, Brazil
- Colombian National Academy of Medicine, Bogota, D.C., Colombia
| | - Abduljabbar Alhammoud
- Department of Orthopedic Surgery, University of Arizona College of Medicine, Tucson, AZ, USA
| | | | | | | | - Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, FL, USA
- Orlando College of Osteopathic Medicine, Orlando, FL, USA
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Amen TB, Song J, Mai E, Rudisill SS, Bovonratwet P, Subramanian T, Kaidi AK, Maayan O, Qureshi SA, Iyer S. Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors. Spine J 2023; 23:1848-1857. [PMID: 37716549 DOI: 10.1016/j.spinee.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND CONTEXT Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. PURPOSE This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES Hospital readmission within 30 postoperative days. METHODS Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. RESULTS A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). CONCLUSION This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA.
| | - Junho Song
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Eric Mai
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Samuel S Rudisill
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Tejas Subramanian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Austin K Kaidi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Omri Maayan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sheeraz A Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
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Tani S, Okano I, Dodo Y, Camino-Willhuber G, Caffard T, Schönnagel L, Chiapparelli E, Amoroso K, Tripathi V, Arzani A, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sokunbi G, Sama AA. Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients. Spine (Phila Pa 1976) 2023; 48:1427-1435. [PMID: 37389987 DOI: 10.1097/brs.0000000000004767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
STUDY DESIGN/SETTING A retrospective observational study. OBJECTIVE The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient. SUMMARY OF BACKGROUND DATA Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion. MATERIALS AND METHODS Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h). RESULTS In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management. CONCLUSIONS Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.
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Affiliation(s)
- Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | | | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, NY
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Silber JH, Rosenbaum PR, Reiter JG, Jain S, Ramadan OI, Hill AS, Hashemi S, Kelz RR, Fleisher LA. The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity. Med Care 2023; 61:328-337. [PMID: 36929758 PMCID: PMC10079624 DOI: 10.1097/mlr.0000000000001836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased. OBJECTIVE To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs. RESEARCH DESIGN Matched cohort study. SUBJECTS Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures. MEASURES Seven and 30-day revisit and complication rates. RESULTS For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately. CONCLUSIONS The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.
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Affiliation(s)
- Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- The Department of Pediatrics, The University of
Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School,
The University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Statistics and Data Science, The Wharton
School, The University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Surgery, The Perelman School of Medicine, The
University of Pennsylvania
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of
Philadelphia, Philadelphia, PA
| | - Rachel R. Kelz
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Surgery, The Perelman School of Medicine, The
University of Pennsylvania
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The
University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, The
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Perioperative Outcomes Research and
Transformation, The University of Pennsylvania, Philadelphia, PA
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Schlesinger SM, Gelber BR, Gerber MB, Lorio MP, Block JE. Comparison of Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center and Traditional Hospital Settings, Part 1: Multi-Center Assessment of Surgical Safety. J Pers Med 2023; 13:jpm13020311. [PMID: 36836545 PMCID: PMC9962815 DOI: 10.3390/jpm13020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/04/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
(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.
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Affiliation(s)
- Scott M. Schlesinger
- Legacy Spine & Neurological Specialists, 8201 Cantrell Road, Ste. 265, Little Rock, AR 72227, USA
| | - Benjamin R. Gelber
- Neurological and Spinal Surgery, Bryan Medical Center West, 2222 S. 16th Street, Ste. 305, Tower B, Lincoln, NE 68502, USA
| | - Mark B. Gerber
- Neuroscience and Spine Associates, 6101 Pine Ridge Road, Ste. 101, Naples, FL 34119, USA
| | - Morgan P. Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Jon E. Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
- Correspondence: ; Tel.: +415-775-7947
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Hersh AM, Dedrickson T, Gong JH, Jimenez AE, Materi J, Veeravagu A, Ratliff JK, Azad TD. Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019. Neurosurgery 2023; 92:963-970. [PMID: 36700751 DOI: 10.1227/neu.0000000000002306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tara Dedrickson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Mora C, Sampedro I, Rodríguez-Caballero A, Martín-Láez R, Ortega-Roldán M, Venkatraghavan L, Fernández-Miera M, Varea M, Pajaron-Guerrero M, Esteban J, Moreno B, Manzano A, Ruiz I, Martino J, Zadeh G, Bernstein M, Velásquez C. Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program. Neurosurg Focus 2022; 52:E8. [DOI: 10.3171/2022.3.focus2242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process.
METHODS
An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol’s implementation were identified from the feedback of all participants.
RESULTS
An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient’s admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care.
CONCLUSIONS
Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.
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Affiliation(s)
- Carla Mora
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla
| | - Isabel Sampedro
- Hospital-at-Home Department, Hospital Universitario Marqués de Valdecilla
| | | | - Rubén Martín-Láez
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla
- Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Cantabria
| | - Marta Ortega-Roldán
- Ciencias Jurídicas y Empresariales, Universidad de Cantabria, Santander, Cantabria, Spain
- Medtronic Ibérica, Madrid, Spain
| | - Lashmi Venkatraghavan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University of Toronto
| | | | - Mar Varea
- Hospital-at-Home Department, Hospital Universitario Marqués de Valdecilla
| | | | - Jesus Esteban
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla
| | - Blanca Moreno
- Hospital-at-Home Department, Hospital Universitario Marqués de Valdecilla
| | - Asunción Manzano
- Hospital-at-Home Department, Hospital Universitario Marqués de Valdecilla
| | - Isabel Ruiz
- Department of Anesthesiology, Hospital Universitario Marqués de Valdecilla
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla
- Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Cantabria
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Mark Bernstein
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - Carlos Velásquez
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla
- Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Cantabria
- Department of Anatomy and Cell Biology, Universidad de Cantabria, Santander, Cantabria; and
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Cha EDK, Lynch CP, Hrynewycz NM, Geoghegan CE, Mohan S, Jadczak CN, Parrish JM, Jenkins NW, Singh K. Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review. Clin Spine Surg 2022; 35:118-126. [PMID: 34183543 DOI: 10.1097/bsd.0000000000001225] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a systematic review study. PURPOSE This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC). BACKGROUND Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates. METHODS This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories. RESULTS Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092). CONCLUSIONS After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.
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Affiliation(s)
- Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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11
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Alvi MA, Wahood W, Kurian SJ, Zreik J, Jeffery MM, Naessens JM, Spinner RJ, Bydon M. Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting. J Neurosurg Spine 2021; 35:787-795. [PMID: 34416720 DOI: 10.3171/2021.2.spine201820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. METHODS For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. RESULTS A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. CONCLUSIONS These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.
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Affiliation(s)
- Mohammed Ali Alvi
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Waseem Wahood
- 3Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida
| | | | - Jad Zreik
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Molly M Jeffery
- 5Division of Health Care Policy and Research, Department of Health Sciences Research, and
| | - James M Naessens
- 5Division of Health Care Policy and Research, Department of Health Sciences Research, and
- 6Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Robert J Spinner
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW Same-day protocols for craniotomy have been demonstrated to be feasible and safe. Its several benefits include decreased hospital costs, less nosocomial complications, fewer case cancellations, with a high degree of patient satisfaction. This paper reviews the most recent publications in the field of same-day discharge after craniotomy. RECENT FINDINGS Since 2019, several studies on same-day neurosurgical procedures were published. Ambulatory craniotomy protocols for brain tumor were successfully implemented in more centers around the world, and for the first time, in a developing country. Additional information emerged on predictors for successful early discharge, and the barriers and enablers of same-day craniotomy programs. Moreover, the cost benefits of same-day craniotomy were reaffirmed. SUMMARY Same- day discharge after craniotomy is feasible, safe and continues to expand to a wider variety of procedures, in new institutions and countries. There are several benefits to ambulatory surgery. Well-established protocols for perioperative management are essential to the success of early discharge programs. With continued research, these protocols can be refined and implemented in more institutions globally, ultimately to provide better, more efficient care for neurosurgical patients.
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A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion. J Am Acad Orthop Surg 2021; 29:758-766. [PMID: 33428349 DOI: 10.5435/jaaos-d-20-00894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/07/2020] [Indexed: 02/01/2023] Open
Abstract
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.
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Preoperative Criteria Predict Operative Time Variability Within Tympanoplasty Procedures. Otol Neurotol 2021; 42:e1049-e1055. [PMID: 34191787 DOI: 10.1097/mao.0000000000003146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify preoperative patient and surgical parameters that predict operative time variability within tympanoplasty current procedural terminology (CPT) codes. STUDY DESIGN Retrospective. SETTING Tertiary referral center. PATIENTS One hundred twenty eight patients who underwent tympanoplasty (CPT code 69631) or tympanoplasty with ossicular chain reconstruction (69633) by a single surgeon over 3 years. INTERVENTIONS Procedures were preoperatively assigned a complexity modifier: Level 1 (small or posterior perforation able to be repaired via transcanal approach), Level 2 (large perforation or other factor requiring postauricular approach), or Level 3 (cholesteatoma or severe infection). MAIN OUTCOME MEASURES Total in-room time (nonoperative time plus actual operative time). RESULTS Consideration of preoperative parameters including surgical complexity, surgical facility, use of facial nerve monitoring, laser usage, resident involvement, revision surgery, and underlying patient characteristics (American Society of Anesthesiologists [ASA] score, body mass index [BMI]) accounted for up to 69% of surgical time variance. Across both CPT codes, surgical complexity levels accurately stratified operative times (p < 0.05). Total time was longer (by 30.0 min for 69631, 55.4 min for 69633) in Level 3 procedures compared with Level 2, while Level 1 cases were shorter (27.6, 33.9 min). Resident involvement added 25 and 32 minutes to total time (p < 0.02). Nonoperative preparation times were longer (22.1, 15.4 min) in the main hospital compared with ambulatory surgical center (p < 0.001). CONCLUSIONS There is significant surgical time variability within tympanoplasty CPT codes, which can be accurately predicted by the preoperative assignment of complexity level modifiers and consideration of patient and surgical factors. Application of complexity modifiers can enable more efficient surgical scheduling.
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High-risk surgical procedures and semi-emergent surgical procedures for ambulatory surgery. Curr Opin Anaesthesiol 2020; 33:718-723. [PMID: 33002955 DOI: 10.1097/aco.0000000000000918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review evaluates more complex surgical procedures to see whether they might be suitable for ambulatory surgery. Operations that have shown an increasing daycase rate in England include thyroidectomy, joint arthroplasty, spinal surgery and hysterectomy, and these procedures are evaluated. Similarly, there have been recent developments in the management of nonelective ambulatory surgery with more timely throughput and home discharge for suitable patients. RECENT FINDINGS Caveats on patient selection with the development of focussed educational programmes about the proposed operation have assisted with the development of shorter discharge times. Strict antiemetic guidelines, multimodal analgesic protocols and postoperative multidisciplinary follow-up are core components of the pathway for effective ambulatory management. Communication after discharge should include phone calls from the Ambulatory Unit and easy access to the medical staff who conducted their operation. SUMMARY There should be no reason why more complex surgical operations could not be included in a day surgery armamentarium. Similarly, the evidence for more effective use of timely emergency care with shortened length of stay is increasing.
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