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Tiao J, Rosenberg AM, Hoang T, Zaidat B, Wang K, Gladstone JD, Anthony SG. Ambulatory Surgery Centers Reduce Patient Out-of-Pocket Expenditures for Isolated Arthroscopic Rotator Cuff Repair, but Patient Out-of-Pocket Expenditures Are Increasing at a Faster Rate Than Total Healthcare Utilization Reimbursement From Payers. Arthroscopy 2024; 40:1727-1736.e1. [PMID: 38949274 DOI: 10.1016/j.arthro.2023.10.026] [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: 05/23/2023] [Revised: 10/16/2023] [Accepted: 10/20/2023] [Indexed: 07/02/2024]
Abstract
PURPOSE To categorize and trend annual out-of-pocket expenditures for arthroscopic rotator cuff repair (RCR) patients relative to total healthcare utilization (THU) reimbursement and compare drivers of patient out-of-pocket expenditures (POPE) in a granular fashion via analyses by insurance type and surgical setting. METHODS Patients who underwent outpatient arthroscopic RCR in the United States from 2013 to 2018 were identified from the IBM MarketScan Database. Primary outcome variables were total POPE and THU reimbursement, which were calculated for all claims in the 9-month perioperative period. Trends in outcome variables over time and differences across insurance types were analyzed. Multivariable analysis was performed to investigate drivers of POPE. RESULTS A total of 52,330 arthroscopic RCR patients were identified. Between 2013 and 2018, median POPE increased by 47.5% ($917 to $1,353), and median THU increased by 9.3% ($11,964 to $13,076). Patients with high deductible insurance plans paid $1,910 toward their THU, 52.5% more than patients with preferred provider plans ($1,253, P = .001) and 280.5% more than patients with managed care plans ($502, P = .001). All components of POPE increased over the study period, with the largest observed increase being POPE for the immediate procedure (P = .001). On multivariable analysis, out-of-network facility, out-of-network surgeon, and high-deductible insurance most significantly increased POPE. CONCLUSIONS POPE for arthroscopic RCR increased at a higher rate than THU over the study period, demonstrating that patients are paying an increasing proportion of RCR costs. A large percentage of this increase comes from increasing POPE for the immediate procedure. Out-of-network facility status increased POPE 3 times more than out-of-network surgeon status, and future cost-optimization strategies should focus on facility-specific reimbursements in particular. Last, ambulatory surgery centers (ASCs) significantly reduced POPE, so performing arthroscopic RCRs at ASCs is beneficial to cost-minimization efforts. CLINICAL RELEVANCE This study highlights that although payers have increased reimbursement for RCR, patient out-of-pocket expenditures have increased at a much higher rate. Furthermore, this study elucidates trends in and drivers of patient out-of-pocket payments for RCR, providing evidence for development of cost-optimization strategies and counseling of patients undergoing RCR.
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Affiliation(s)
- Justin Tiao
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Ashley M Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Timothy Hoang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Kevin Wang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - James D Gladstone
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Shawn G Anthony
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A..
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Heo KY, Bonsu JM, Khawaja S, Karzon A, Rajan PV, Barber LA, Yoon ST. Database analysis comparing incidence and complication rates between inpatient and outpatient laminotomies for lumbar disc herniation. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100328. [PMID: 38966040 PMCID: PMC11222817 DOI: 10.1016/j.xnsj.2024.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 07/06/2024]
Abstract
Background Lumbar disc herniation (LDH) is a common condition that can be characterized with disabling pain. While most patients recover without surgery, some still require operative intervention. The epidemiology and trends of laminotomy for LDH have not been recently studied, and current practice patterns might be different from historical norms. This study aimed to investigate the trends of inpatient and outpatient laminotomies for LDH and compare complication rates between these two sites of service. Methods A large, national database was utilized to identify patients > 8 years old who underwent a laminotomy for LDH between 2009 and 2019. Two cohorts were created based on site of surgery: inpatient versus outpatient. The outpatient cohort was defined as patients who had a length of stay less than 1 day without any associated hospitalization. Epidemiologic analyses for these cohorts were performed by demographics. Patients in both groups were then 1:1 propensity-score matched based on age, sex, insurance type, geographic region, and comorbidities. Ninety-day postoperative complications were compared between cohorts utilizing multivariate logistic regressions. Results The average incidence of laminotomy for LDH was 13.0 per 10,000 persons-years. Although the national trend in incidence had not changed from 2009 to 2019, the proportion of outpatient laminotomies significantly increased in this time period (p=.02). Outpatient laminotomies were more common among younger and healthier patients. Patients with inpatient laminotomies had significantly higher rates of surgical site infections (odds ratio [OR] 1.61, p<.001), venous thromboembolism (VTE) (OR 1.96, p<.001), hematoma (OR 1.71, p<.001), urinary tract infections (OR 1.41, p<.001), and acute kidney injuries (OR 1.75, p=.001), even when controlling for selected confounders. Conclusions Our study demonstrated an increasing trend in the performance of laminotomy for LDH toward the outpatient setting. Even when controlling for certain confounders, patients requiring inpatient procedures had higher rates of postoperative complications. This study highlights the importance of carefully evaluating the advantages and disadvantages of performing these procedures in an outpatient versus inpatient setting.
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Affiliation(s)
- Kevin Y. Heo
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Janice M. Bonsu
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sameer Khawaja
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Anthony Karzon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Prashant V. Rajan
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Lauren A. Barber
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sangwook Tim Yoon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
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Patel MR, Jacob KC, Prabhu MC, Shah VP, Vanjani NN, Pawlowski H, Singh K. Anterior Cervical Discectomy and Fusion Versus Cervical Disc Replacement for a Workers' Compensation Population in an Ambulatory Surgical Center. Clin Spine Surg 2024; 37:E37-E42. [PMID: 37853571 DOI: 10.1097/bsd.0000000000001543] [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: 04/26/2022] [Accepted: 07/19/2023] [Indexed: 10/20/2023]
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVE To evaluate patient-reported outcome measures (PROM) and minimal clinically important difference (MCID) achievement outcomes between anterior cervical discectomy and fusion (ACDF) and cervical disk replacement (CDR) in the Workers' Compensation (WC) population. SUMMARY OF BACKGROUND DATA No studies to our knowledge have compared PROMs and MCID attainment between ACDF and CDR among patients with WC insurance undergoing surgery in an outpatient ambulatory surgical center (ASC). METHODS WC insurance patients undergoing primary, single/double-level ACDF/CDR in an ASC were identified. Patients were divided into ACDF versus CDR. PROMs were collected at preoperative/6-week/12-week/6-month/1-year timepoints, including PROMIS-PF, SF-12 PCS/MCS, VAS neck/arm, and NDI. RESULTS Seventy-nine patients were included, 51 ACDF/28 CDR. While operative time (56.4 vs. 54.4 min), estimated blood loss (29.2 vs. 25.9 mL), POD0 pain (4.9 vs. 3.8), and POD0 narcotic consumption (21.2 vs. 14.5 oral morphine equivalents) were higher in ACDF patients, none reached statistical significance ( P >0.050, all). One-year arthrodesis rate was 100.0% among ACDF recipients with available imaging (n=36). ACDF cohort improved from preoperative for PROMIS-PF from 12 weeks to 1 year, SF-12 PCS at 6 months, all timepoints for VAS neck/arm, and 12 weeks/6 months for NDI ( P ≤0.044, all). CDR cohort improved from preoperative for PROMIS-PF at 6 months, VAS neck/arm from 12 weeks to 1 year, and NDI at 12 weeks/6 months ( P ≤0.049, all). CDR cohort reported significantly lower VAS neck at 12 weeks/1 year and VAS arm at 12 weeks ( P ≤0.039, all). MCID achievement rates did not differ. CONCLUSION While operative duration/estimated blood loss/acute postoperative pain/narcotic consumption were, on average, higher among ACDF recipients, these were not statistically significant, possibly due to the limited sample size. ACDF and CDR ASC patients generally demonstrated comparable arm pain/disability/physical function/mental health, though neck pain was significantly lower at multiple timepoints among CDR patients. Clinically meaningful PROM improvements were comparable. Larger, multicentered studies are required to confirm our results.
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Affiliation(s)
- Madhav R Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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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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Monk SH, Hani U, Pfortmiller D, Adamson TE, Bohl MA, Branch BC, Kim PK, Smith MD, Holland CM, McGirt MJ. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis. Neurosurgery 2023; 93:867-874. [PMID: 37067954 DOI: 10.1227/neu.0000000000002483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/09/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series. OBJECTIVE To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting. METHODS A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed. RESULTS There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery. CONCLUSION In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Ummey Hani
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Michael A Bohl
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
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Monk SH, Hani U, Pfortmiller D, Dyer EH, Smith MD, Kim PK, Bohl MA, Coric D, Adamson TE, Holland CM, McGirt MJ. Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis. Neurosurgery 2023; 93:628-635. [PMID: 36995083 DOI: 10.1227/neu.0000000000002464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/26/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking. OBJECTIVE To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up. METHODS A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility. CONCLUSION Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Ummey Hani
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - E Hunter Dyer
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Michael A Bohl
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Domagoj Coric
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
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Ye J, Zielinski E, Richardson S, Petrone B, McCarthy MM, Boody B. Is It Safe to Perform True Outpatient Multilevel ACDFs in a Surgery Center? Clin Spine Surg 2023; 36:151-153. [PMID: 36727974 DOI: 10.1097/bsd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Jason Ye
- Indiana Spine Group, Carmel Carmel
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Canseco JA, Karamian BA, Lambrechts MJ, Issa TZ, Conaway W, Minetos PD, Bowles D, Alexander T, Sherman M, Schroeder GD, Hilibrand AS, Vaccaro AR, Kepler CK. Risk stratification of patients undergoing outpatient lumbar decompression surgery. Spine J 2023; 23:675-684. [PMID: 36642254 DOI: 10.1016/j.spinee.2023.01.002] [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: 06/17/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND CONTEXT Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSE To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTING Retrospective single-institution cohort. PATIENT SAMPLE A total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURES Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODS Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTS A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.
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Affiliation(s)
- Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - William Conaway
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Paul D Minetos
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Daniel Bowles
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Tyler Alexander
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Monk SH, Zeitouni D, Cowan D, Rossi VJ, Parish JM, Dyer EH, Smith MD, Kim PK, Adamson TE. Feasibility and Safety of Microendoscopic Posterior Cervical Foraminotomy in an Ambulatory Surgery Center: A Longitudinal Experience with 1000 Cases. World Neurosurg 2023; 173:e228-e233. [PMID: 36787856 DOI: 10.1016/j.wneu.2023.02.035] [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: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE Ambulatory surgery centers (ASCs) have become an increasingly attractive setting for spine surgery in recent decades. Although posterior cervical foraminotomy (PCF) is widely performed in ASCs, there are no studies supporting the safety of this practice. We aimed to demonstrate the feasibility and safety of microendoscopic (MED)-PCF in a large cohort of patients at a freestanding ASC. METHODS Consecutive patients undergoing MED-PCF for unilateral cervical radiculopathy at a single freestanding ASC from January 2013 to December 2020 were queried. Standard demographic and perioperative data were collected. Outcomes included need for inpatient transfer, perioperative complications, 30-day readmission, 30-day reoperation, and clinical improvement according to the Odom criteria. RESULTS A total of 1106 patients underwent MED-PCF during the study period. Mean age was 53.3 ± 10.3 years. Most patients underwent decompression at C5-6 (31.4%) or C6-7 (51.9%). Approximately 10% underwent surgery at multiple levels. Mean operative time was 40.0 ± 16.4 minutes. There were no intraoperative or immediate postoperative complications. All patients were discharged home within a few hours of surgery. The rates of 30-day readmission (0.81%) and reoperation (0.36%) were exceedingly low. Nearly 3 quarters of patients (73.7%) achieved a good or excellent clinical outcome (73.7%) according to the Odom criteria. CONCLUSIONS MED-PCF can be performed in a freestanding ASC with exceedingly low rates of perioperative complications and short-term readmission or reoperation. Our findings support the ongoing migration of PCF from the hospital to the ambulatory setting. Future studies assessing patient-reported outcomes and long-term reoperation rates are necessary.
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Affiliation(s)
- Steve H Monk
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA.
| | - Daniel Zeitouni
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - David Cowan
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Vincent J Rossi
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Jonathan M Parish
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - E Hunter Dyer
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Mark D Smith
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Paul K Kim
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
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Epstein NE. Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s)? Surg Neurol Int 2023; 14:110. [PMID: 37151427 PMCID: PMC10159315 DOI: 10.25259/sni_175_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background:
Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s: i.e. discharges 4-7.5 hr. postoperatively) that meet the following stringent “exclusion criteria”; elevated Body Mass Index (BMI), major comorbidities, age > 65, American Society of Anesthesiology (ASA) scores > II, and largely multilevel ACDF.
Materials:
Presently, most ACDF are still being performed in hospital-based outpatient surgical centers (HBSC: utilizing 23-hour stays), or as inpatients.
Results:
Notably, unreliable disparate study designs involving very different patient populations resulted in nearly comparable, but implausible outcomes for 1-level vs. multilevel ACDF series performed in ASC. A summary of these outcome data included the following rates of; i.e. postoperative hospital transfers (0-6%), 30-day (up to 2.2%), and up to 90 day (2.2%) emergency department (ED) visits, readmissions, and reoperations.
Conclusion:
Nevertheless, it is just common sense that “less should be less”, that 1-level ACDF should involve less risk compared with multilevel ACDF procedures performed in ASC.
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Thakur V, Kessler B, Khan MB, Hodge JO, Brandmeir NJ. Outpatient Deep Brain Stimulation Surgery Is a Safe Alternative to Inpatient Admission. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00656. [PMID: 36929766 DOI: 10.1227/ons.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is usually performed as an inpatient procedure. The COVID-19 pandemic effected a practice change at our institution with outpatient DBS performed because of limited inpatient and surgical resources. Although this alleviated use of hospital resources, the comparative safety of outpatient DBS surgery is unclear. OBJECTIVE To compare the safety and incidence of early postoperative complications in patients undergoing DBS procedures in the outpatient vs inpatient setting. METHODS We retrospectively reviewed all outpatient and inpatient DBS procedures performed by a single surgeon between January 2018 and November 2022. The main outcome measures used for comparison between the 2 groups were total complications, length of stay, rate of postoperative infection, postoperative hemorrhage rate, 30-day emergency department (ED) visits and readmissions, and IV antihypertensive requirement. RESULTS A total of 44 outpatient DBS surgeries were compared with 70 inpatient DBS surgeries. The outpatient DBS cohort had a shorter mean postoperative stay (4.19 vs 39.59 hours, P = .0015), lower total complication rate (2.3% vs 12.8%, P = .1457), and lower wound infection rate (0% vs 2.9%, P = .52) compared with the inpatient cohort, but the difference in complications was not statistically significant. In the 30-day follow-up period, ED visits were similar between the cohorts (6.8% vs 7.1%, P = .735), but no outpatient DBS patient required readmission, whereas all inpatient DBS patients visiting the ED were readmitted (P = .155). CONCLUSION Our study demonstrates that DBS can be safely performed on an outpatient basis with same-day hospital discharge and close continuous monitoring.
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Affiliation(s)
- Vishal Thakur
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
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12
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Bovonratwet P, Kapadia M, Chen AZ, Vaishnav AS, Song J, Sheha ED, Albert TJ, Gang CH, Qureshi SA. Opioid prescription trends after ambulatory anterior cervical discectomy and fusion. Spine J 2023; 23:448-456. [PMID: 36427653 DOI: 10.1016/j.spinee.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND CONTEXT Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSE To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURES Rate, amount, and type of perioperative opioid prescription. METHODS Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTS A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONS Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Milan Kapadia
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Aaron Z Chen
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Avani S Vaishnav
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Junho Song
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Evan D Sheha
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Todd J Albert
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Catherine H Gang
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA
| | - Sheeraz A Qureshi
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA.
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Monk SH, Rossi VJ, Atkins TG, Karimian B, Pfortmiller D, Kim PK, Adamson TE, Smith MD, McGirt MJ, Holland CM, Deshmukh VR, Branch BC. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol. World Neurosurg 2023; 171:e471-e477. [PMID: 36526224 DOI: 10.1016/j.wneu.2022.12.047] [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: 10/02/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Vincent J Rossi
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tyler G Atkins
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Brandon Karimian
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Vinay R Deshmukh
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
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14
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Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes. Spine (Phila Pa 1976) 2023; 48:278-287. [PMID: 36692157 DOI: 10.1097/brs.0000000000004519] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN/SETTING Systematic review. OBJECTIVE The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion. SUMMARY OF BACKGROUND As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices. MATERIALS AND METHODS This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes. RESULTS The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs. CONCLUSION There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis. LEVEL OF EVIDENCE Level III.
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15
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Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis. Spine (Phila Pa 1976) 2023; 48:155-163. [PMID: 36607626 DOI: 10.1097/brs.0000000000004500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. SUMMARY OF BACKGROUND DATA Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. MATERIALS AND METHODS A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. CONCLUSION Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.
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16
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Monk SH, O'Brien M, Bernard JD, Kim PK. Is Thoracic Paddle Lead Spinal Cord Stimulator Implantation Safe in an Ambulatory Surgery Center? World Neurosurg 2023; 170:e436-e440. [PMID: 36379362 DOI: 10.1016/j.wneu.2022.11.030] [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: 10/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Spinal cord stimulation is an effective treatment modality for chronic pain. Although percutaneous leads are commonly placed in the outpatient setting, paddle leads are typically implanted in the inpatient setting. Given the substantial cost savings associated with the ambulatory setting, we aimed to demonstrate the feasibility and safety of thoracic paddle lead implantation in a freestanding ambulatory surgery center (ASC). METHODS Consecutive patients undergoing thoracic paddle lead implantation at a single freestanding ASC from January 2015 to December 2020 were queried. Demographic, perioperative, and outcome data were collected. Primary outcomes were incidence of intraoperative or immediate postoperative complications and need for inpatient transfer. Secondary outcomes included readmission at 30 and 90 days and reoperation at 30 days, 90 days, and 1 year. RESULTS A total of 46 patients underwent ambulatory thoracic paddle lead implantation over the study period. Two patients (4.3%) suffered an immediate postoperative complication requiring return to surgery at the ASC-one for an epidural hematoma, and one for a flank hematoma. All but one patient (97.8%) were discharged home on the day of surgery. The overall 30- and 90-day readmission rates were 4.3% and 6.5%, respectively. One patient (2.2%) required reoperation for a mechanical complication. No device-related infections were noted during the follow-up period. CONCLUSIONS Thoracic laminotomy for paddle lead spinal cord stimulator implantation can be performed in a freestanding ASC with complication rates comparable to the hospital setting. Future comparative studies that assess clinical outcomes and cost are necessary to determine the cost-effectiveness of the ambulatory setting.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Matthew O'Brien
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; University of South Carolina School of Medicine - Columbia, Columbia, South Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
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Adamczyk K, Koszela K, Zaczyński A, Niedźwiecki M, Brzozowska-Mańkowska S, Gasik R. Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2098. [PMID: 36767465 PMCID: PMC9915556 DOI: 10.3390/ijerph20032098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 06/18/2023]
Abstract
Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.
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Affiliation(s)
- Kamil Adamczyk
- Department of Anaesthesiology and Intensive Therapy, Central Clinical Hospital of the Ministry of Interior and Administration in Warsaw, 02-507 Warsaw, Poland
- Department of Anaesthesiology, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 02-637 Warsaw, Poland
| | - Kamil Koszela
- Neuroorthopedics and Neurology Clinic and Polyclinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Artur Zaczyński
- Department of Neurosurgery, Central Clinical Hospital of the Ministry of Interior and Administration in Warsaw, 02-507 Warsaw, Poland
| | - Marcin Niedźwiecki
- Department of Neurosurgery, Central Clinical Hospital of the Ministry of Interior and Administration in Warsaw, 02-507 Warsaw, Poland
| | - Sybilla Brzozowska-Mańkowska
- Department of Anaesthesiology, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 02-637 Warsaw, Poland
| | - Robert Gasik
- Neuroorthopedics and Neurology Clinic and Polyclinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
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Prabhu MC, Jacob KC, Patel MR, Nie JW, Hartman TJ, Singh K. Multimodal analgesic protocol for cervical disc replacement in the ambulatory setting: Clinical case series. J Clin Orthop Trauma 2022; 35:102047. [PMID: 36345544 PMCID: PMC9636032 DOI: 10.1016/j.jcot.2022.102047] [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: 06/30/2022] [Revised: 09/04/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background Effective pain management is paramount for outpatient surgical success. This study aims to report a case series of patients undergoing cervical disc replacement (CDR) in an ambulatory surgery center (ASC) with the use of an enhanced multimodal analgesic (MMA) protocol. Methods Primary, single-/2-level CDR procedures at an ASC with an enhanced MMA protocol were included. ASC patients were discharged day of surgery. Patient-reported outcome measures (PROMs) were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included Visual Analogue Scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), and 12-Item Short-Form Physical and Mental Composite Score (SF-12 PCS/SF-12 MCS). A t-test assessed postoperative PROM improvement from baseline. MCID achievement was determined by comparing ΔPROM scores to previously established thresholds. Results 106 patients were included, 76 single-level and 30 2-level. Most single-levels occurred at C5-C6, most 2-levels at C5-C7. One 2-level patient developed a hematoma 5 days postoperatively and underwent revision for evacuation. Five patients reported postoperative dysphagia; all were quickly resolved. One patient had an episode of seizure secondary to serotonin syndrome from concealed drug use. Patient was reintubated, transferred, and treated for serotonin syndrome. Two patients experienced postoperative nausea/vomiting. Cohort significantly improved from baseline for all PROMS at all timepoints except SF-12 MCS at 1-year/2-years and SF-12 PCS at 2 years (p < 0.047, all). Overall MCID achievement rates were: VAS arm (48.7%), VAS neck (69.1%), NDI (98.9%), SF-12 MCS (50.0%), SF-12 PCS (54.6%), and PROMIS-PF (73.4%). Conclusion Outpatient CDR, incorporating an enhanced MMA protocol, can be safely and effectively performed with proper patient selection and surgical technique. Patients saw timely discharge, well-controlled postoperative pain, and favorable long-term outcomes.
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Affiliation(s)
- Michael C. Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Kevin C. Jacob
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Madhav R. Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - James W. Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Timothy J. Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
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Hartman TJ, Nie JW, Pawlowski H, Prabhu MC, Vanjani NN, Singh K. Impact of age within younger populations on outcomes following cervical surgery in the ambulatory setting. J Clin Orthop Trauma 2022; 34:102016. [PMID: 36164388 PMCID: PMC9508464 DOI: 10.1016/j.jcot.2022.102016] [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: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To determine the effect of age within the younger population seen at ambulatory surgical centers on patient-reported outcome measures (PROMs) after cervical spine surgery. Methods Patients of age <65 years undergoing single-level anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) were included. Patients were divided by mean age of initial population (46 years). PROMs included Patient-reported Outcome Measurement Information System Physical Function (PROMIS-PF), 12-Item Short-Form Physical Component Survey (SF-12 PCS), Visual Analog Scale (VAS) neck, VAS arm, Neck Disability Index (NDI) collected preoperatively and at postoperative time points up to 2 years. Results 138 patients were included, with 66 patients <46 years. Both cohorts demonstrated improvement from preoperative baseline with regard to all studied PROMs at multiple time points postoperatively (p ≤ 0.042, all). Between groups, the older cohort demonstrated greater mean PROMIS-PF scores preoperatively and at 6 weeks (p ≤ 0.011, both), while VAS arm scores were lower in the older group at 1 year (p = 0.002), and NDI scores were lower in the older group at 6 weeks and 1 year (p < 0.027, both). Minimal Clinically Important Difference (MCID) achievement rates were greater in the younger group in PROMIS PF at 2 years (p = 0.002), and in the older group in VAS arm score at 1 year (p = 0.007). Conclusion Both cohorts showed significant improvement at multiple postoperative time points for all PROMs. Between groups, the older group reported more favorable physical function, VAS arm, and NDI scores at several time points. However, MCID achievement rates only significantly differed in two PROMs at singular time points. Difference in age in patients <65 years likely does not significantly affect long-term outcomes after cervical spine surgery.
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Affiliation(s)
- Timothy J. Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - James W. Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Hanna Pawlowski
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Michael C. Prabhu
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Nisheka N. Vanjani
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
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Carlson BC, Dawson JM, Beauchamp EC, Mehbod AA, Mueller B, Alcala C, Mullaney KJ, Perra JH, Pinto MR, Schwender JD, Shafa E, Transfeldt EE, Garvey TA. Choose Wisely: Surgical Selection of Candidates for Outpatient Anterior Cervical Surgery Based on Early Complications Among Inpatients. J Bone Joint Surg Am 2022; 104:1830-1840. [PMID: 35869896 DOI: 10.2106/jbjs.21.01356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are attractive targets for transition to the outpatient setting. We assessed the prevalence of rapid responses and major complications in the inpatient setting following 1 or 2-level ACDFs and CDAs. We evaluated factors that may place patients at greater risk for a rapid response or a postoperative complication. METHODS This was an institutional review board-approved, retrospective cohort study of adults undergoing 1 or 2-level ACDF or CDA at 1 hospital over a 2-year period (2018 and 2019). Data on patient demographic characteristics, surgical procedures, and comorbidities were collected. Rapid response events were identified by hospital floor staff and involved acute changes in a patient's clinical condition. Complications were events that were life-threatening, required an intervention, or led to delayed hospital discharge. RESULTS In this study, 1,040 patients were included: 888 underwent ACDF and 152 underwent CDA. Thirty-six patients (3.5%) experienced a rapid response event; 22% occurred >24 hours after extubation. Patients having a rapid response event had a significantly higher risk of developing a complication (risk ratio, 10; p < 0.01) and had a significantly longer hospital stay. Twenty-four patients (2.3%) experienced acute complications; 71% occurred >6 hours after extubation. Patients with a complication were older and more likely to be current or former smokers, have chronic obstructive pulmonary disease, have asthma, and have an American Society of Anesthesiologists (ASA) score of >2. The length of the surgical procedure was significantly longer in patients who developed a complication. All patients who developed dysphagia had a surgical procedure involving C4-C5 or more cephalad. Patients with a rapid response event or complication were more commonly undergoing revision surgical procedures. CONCLUSIONS Rapid response and complications are uncommon following 1 or 2-level ACDFs or CDAs but portend a longer hospital stay and increased morbidity. Revision surgical procedures place patients at higher risk for rapid responses and complications. Additionally, older patients, patients with chronic obstructive pulmonary disease or asthma, patients who are current or former smokers, and patients who have an ASA score of ≥3 are at increased risk for postoperative complications. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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21
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ON Path: outpatient nonunion pathway for lower-extremity nonunions. OTA Int 2022; 5:e218. [PMID: 36569112 PMCID: PMC9782313 DOI: 10.1097/oi9.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 06/03/2022] [Accepted: 07/06/2022] [Indexed: 11/05/2022]
Abstract
Objectives The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Design Retrospective case series. Setting Tertiary referral hospital and hospital outpatient department. Patients All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50). Intervention Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Main Outcome Measurements Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union. Results Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months. Conclusions An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature. Level of Evidence IV.
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22
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Wang X, Lin Y, Wang Q, Gao L, Feng F. A Bibliometric Analysis of the Top 100 Cited Articles in Anterior Cervical Discectomy and Fusion. J Pain Res 2022; 15:3137-3156. [PMID: 36311292 PMCID: PMC9604433 DOI: 10.2147/jpr.s375720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
Study design A bibliometric analysis. Objective To identify and analyze the top 100 cited articles in anterior cervical discectomy and fusion. Summary of Background Data Anterior cervical discectomy and fusion (ACDF) is one of the most routine surgical procedures in spine surgery. Many surgeons and academics have researched ACDF thoroughly and published numerous articles. However, there is no relevant bibliometric analysis. Therefore, our study aims to identify and analyze the top 100 cited articles in ACDF to identify the research trends. Methods We searched the Web of Science (WOS) Core Collection database with restrictions and identified the top 100 cited publications in ACDF for analysis. Results The citation counts of the top 100 cited publications ranged from 37 to 361 (mean 67.42). All studies were published between 2008 and 2019, with 2013 and 2015 the most prolific years. The journals Spine and Journal of Neurosurgery-Spine provided the majority of the articles. Overall, the 100 articles came from 12 countries, with the United States being the top producer, followed by China and South Korea. The most frequent keywords were "spine", "anterior cervical discectomy and fusion", "interbody fusion", 'arthrodesis', "follow-up", "decompression", and "ACDF". Conclusion ACDF has been regarded as a classical gold standard in anterior cervical surgery, and the emergence of new surgical procedures has not affected its status. Cervical disc arthroplasty still needs further research and development. As the first bibliometric analysis of ACDF, this bibliometric study is meant to provide guidance for clinicians and scholars to research the development trend of this field.
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Affiliation(s)
- Xun Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Yanze Lin
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Qiongtai Wang
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Liqing Gao
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang310053, People’s Republic of China
| | - Fabo Feng
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China,Correspondence: Fabo Feng, Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, People’s Republic of China, Email
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Mooney J, Michalopoulos GD, Zeitouni D, Sammak SE, Alvi MA, Wang MY, Coric D, Chan AK, Mummaneni PV, Bisson EF, Sherrod B, Haid RW, Knightly JJ, Devin CJ, Pennicooke BH, Asher AL, Bydon M. Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes. J Neurosurg Spine 2022; 37:485-497. [PMID: 35523251 DOI: 10.3171/2022.3.spine211558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery. METHODS The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval. RESULTS A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery. CONCLUSIONS Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.
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Affiliation(s)
- James Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Giorgos D Michalopoulos
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 4School of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Sally El Sammak
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 5Department of Neurological Surgery, University of Miami, Florida
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Andrew K Chan
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Brandon Sherrod
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | | | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Clinton J Devin
- 11Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado; and
| | - Brenton H Pennicooke
- 12Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Mohamad Bydon
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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24
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Chatterjee A, Rbil N, Yancey M, Geiselmann MT, Pesante B, Khormaee S. Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 11:100132. [PMID: 35783006 PMCID: PMC9243295 DOI: 10.1016/j.xnsj.2022.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Nada Rbil
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Michael Yancey
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Matthew T. Geiselmann
- New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Benjamin Pesante
- The University of Connecticut School of Medicine, Farmington, CT, United States
| | - Sariah Khormaee
- Weill Cornell Medical College, New York, NY, United States
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
- Corresponding author: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
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25
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Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures. J Clin Med 2022; 11:jcm11154573. [PMID: 35956188 PMCID: PMC9369519 DOI: 10.3390/jcm11154573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009−2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.
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Neck Disability at Presentation Influences Long Term Clinical Improvement for Neck Pain, Arm Pain, Disability and Physical Function in Patients Undergoing Anterior Cervical Discectomy and Fusion. World Neurosurg 2022; 163:e663-e672. [PMID: 35460906 DOI: 10.1016/j.wneu.2022.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 11/22/2022]
Abstract
STUDY DESIGN Retrospective cohort PURPOSE: To compare perioperative characteristics, patient-reported outcome measures (PROMs) and minimum clinical important difference (MCID) achievement following anterior cervical discectomy and fusion (ACDF) in patients stratified by preoperative neck disability. OVERVIEW OF LITERATURE The Neck Disability Index (NDI) assesses a patient's self-perceived neck disability and is often utilized to assess the efficacy of cervical surgical intervention. Our study evaluates how preoperative severity of patient neck disability influences postoperative clinical improvement following ACDF. METHODS Primary, single or multi-level ACDF procedures were included. PROMs were administered at preoperative/6-week/12-week/6-month/1-year/2-year timepoints and included PROMIS-PF, VAS for neck and arm pain, NDI, and SF-12 PCS. Patients were grouped: preoperative NDI score<50 (mild to moderate neck disability) or NDI score≥50 (Severe neck disability). Demographics/perioperative characteristics/postoperative complications/mean PROMs/MCID achievement rates were compared using chi-squared or Student's t-test. Postoperative improvement from preoperative baseline within each cohort was assessed with paired samples t-test. MCID achievement was determined by comparing ΔPROMs to established thresholds. RESULTS 225 patients were included, 150 NDI<50 and 75 NDI≥50. NDI≥50 cohort was significantly younger(p=0.002). Cohorts did not differ for spinal pathology/operative duration/estimated blood loss/postoperative length of stay/postoperative narcotic consumption/adjacent segment disease rate/1-year arthrodesis rate/6-month pseudoarthrosis rate. Postoperative VAS pain score on POD0 and 1 was significantly increased in NDI≥50 cohort(p<0.048, all). Postoperative complication rates did not differ. All mean PROMs differed at all timepoints(p<0.043, all). NDI<50 patient cohort significantly improved from preoperative baseline for all PROMs and timepoints except SF-12 PCS/PROMIS-PF at 6-weeks. NDI≥50 cohort significantly improved for all PROMs and timepoints except SF-12 PCS at 6-weeks. NDI≥50 cohort demonstrated greater proportion achieving MCID for NDI at 6-weeks/2-years/overall(p<0.037, all). CONCLUSION Both cohorts demonstrated significant long-term clinical improvement for neck pain/arm pain/physical function/neck disability, though patients with severe preoperative neck disability reported inferior mean scores for these outcomes at all timepoints.
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Sastry RA, Hagan MJ, Feler J, Shaaya EA, Sullivan PZ, Abinader JF, Camara JQ, Niu T, Fridley JS, Oyelese AA, Sampath P, Telfeian AE, Gokaslan ZL, Toms SA, Weil RJ. Influence of Time of Discharge and Length of Stay on 30-Day Outcomes After Elective Anterior Cervical Spine Surgery. Neurosurgery 2022; 90:734-742. [PMID: 35383699 DOI: 10.1227/neu.0000000000001893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Encouraging early time of discharge (TOD) for medical inpatients is commonplace and may potentially improve patient throughput. It is unclear, however, whether early TOD after elective spine surgery achieves this goal without a consequent increase in re-presentations to the hospital. OBJECTIVE To evaluate whether early TOD results in increased rates of hospital readmission or return to the emergency department after elective anterior cervical spine surgery. METHODS We analyzed 686 patients who underwent elective uncomplicated anterior cervical spine surgery at a single institution. Logistic regression was used to evaluate the relationship between sociodemographic, procedural, and discharge characteristics, and the outcomes of readmission or return to the emergency department and TOD. RESULTS In multiple logistic regression, TOD was not associated with increased risk of readmission or return to the emergency department within 30 days of surgery. Weekend discharge (odds ratio [OR] 0.33, 95% CI 0.21-0.53), physical therapy evaluation (OR 0.44, 95% CI 0.28-0.71), and occupational therapy evaluation (OR 0.32, 95% CI 0.17-0.63) were all significantly associated with decreased odds of discharge before noon. Disadvantaged status, as measured by area of deprivation index, was associated with increased odds of readmission or re-presentation (OR 1.86, 95% CI 0.95-3.66), although this result did not achieve statistical significance. CONCLUSION There does not appear to be an association between readmission or return to the emergency department and early TOD after elective spine surgery. Overuse of inpatient physical and occupational therapy consultations may contribute to decreased patient throughput in surgical admissions.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Matthew J Hagan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Joshua Feler
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Elias A Shaaya
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Patricia Z Sullivan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jose Fernandez Abinader
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Joaquin Q Camara
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Southcoast Health Brain & Spine, Dartmouth, Massachusetts, USA
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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: 7] [Impact Index Per Article: 3.5] [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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O’Neill CN, Walterscheid ZJ, Carmouche JJ. A Novel Local Cancellous Autograft Source for Anterior Cervical Discectomy With Fusion. Global Spine J 2022; 12:190-197. [PMID: 32990036 PMCID: PMC8907638 DOI: 10.1177/2192568220947741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
STUDY DESIGN Case series. OBJECTIVES Successful clinical outcome scores following anterior cervical discectomy and fusion (ACDF) have been correlated with high fusion rate. Published fusion rates using iliac crest bone graft (ICBG) have been shown to be as high as 100% for single-level fusions in some studies; however, there is potential associated morbidity with ICBG harvest. This technical description and preliminary case series assessed the clinical efficacy and results of a novel grafting technique for ACDF. METHODS Twelve patients underwent novel grafting technique for ACDF in which autograft was procured from the cervical vertebra adjacent to the operative disk. Patients were followed for 2 years using visual analogue pain scale (VAS) and radiological assessment of fusion. RESULTS Patients experienced clinically meaningful reduction of radicular symptoms in the affected arm(s) with an average preoperative VAS score of 5.0 ± 0.8 and an average 2-year postoperative score of 1.108 ± 0.475 (P = .0013). Patients also experienced significant resolution of neck pain with an average preoperative VAS score of 7.1 ± 0.5 and average 2-year postoperative score of 2.708 ± 0.861 (P = .0018). All patients achieved solid fusion by 1 year. There were no major or minor complications noted during follow-up. CONCLUSIONS This procedure allows for both autograft harvest and cervical decompression to be performed through a single incision. In this series, this technique eliminated the morbidity associated with autograft harvest from the iliac crest while achieving high fusion rates and without additional technique-related complications.
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Affiliation(s)
| | | | - Jonathan J. Carmouche
- Virginia Tech-Carilion School or
Medicine, Roanoke VA, USA,Carilion Clinic, Roanoke VA,
USA,Jonathan Carmouche, Carilion Clinic, 2331
Franklin Rd SW, Roanoke, VA 24014, USA.
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30
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Changoor S, Faloon M, Dunn C, Sahai N, Coban D, Saela S, Sinha K, Hwang K, Emami A. Two Attending Surgeons Improve Outcomes of Single Level Anterior Cervical Discectomy and Fusion. J Long Term Eff Med Implants 2022; 32:1-7. [DOI: 10.1615/jlongtermeffmedimplants.2022040313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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31
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Young S, Pollard RJ, Shapiro FE. Pushing the Envelope: New Patients, Procedures, and Personal Protective Equipment in the Ambulatory Surgical Center for the COVID-19 Era. Adv Anesth 2021; 39:97-112. [PMID: 34715983 PMCID: PMC8313519 DOI: 10.1016/j.aan.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Steven Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Richard J Pollard
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Fred E Shapiro
- Harvard Medical School; Department of Anesthesia, Mass Eye and Ear Infirmary, 243 Charles Street, Suite 712, Boston, MA 02114, USA.
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An unusual acute onset hard and small volume epidural blood clotting after anterior cervical discectomy with tetraparetic neurological findings. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.1013491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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33
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Atkins TG, Peters DR, Jernigan SC, Henegar MM, Van Poppel MD, Wait SD. Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital. World Neurosurg 2021; 156:e160-e166. [PMID: 34509680 DOI: 10.1016/j.wneu.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital. METHODS A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases. RESULTS In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05). CONCLUSIONS Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.
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Affiliation(s)
- Tyler G Atkins
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA.
| | - David R Peters
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA
| | - Sarah C Jernigan
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Martin M Henegar
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Mark D Van Poppel
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Scott D Wait
- Carolinas Medical Center, Atrium Health Levine Children's Hosptial, Charlotte, North Carolina, USA; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
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34
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Zhu W, Yan Y, Sun Y, Fan Z, Fang N, Zhang Y, Yin M, Wan H, Mo W, Lu W, Wu X. Implementation of Enhanced Recovery After Surgery (ERAS) protocol for elderly patients receiving surgery for intertrochanteric fracture: a propensity score-matched analysis. J Orthop Surg Res 2021; 16:469. [PMID: 34315507 PMCID: PMC8317361 DOI: 10.1186/s13018-021-02599-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/01/2021] [Indexed: 01/20/2023] Open
Abstract
Purpose Enhanced Recovery After Surgery (ERAS) is a multimodal approach to perioperative care that aims to reduce patient perioperative complications, accelerate patient recovery, and improve patient satisfaction by refining and optimizing all perioperative management processes. By comparing two groups of patients before and after the implementation of ERAS for intertrochanteric fracture (ITF) with a matching analysis of propensity score (PS), we aimed to demonstrate that the implementation of ERAS protocol shortens the length of hospital stay (LOS), reduces pain, decreases the incidence of postoperative complications, and promotes functional recovery of the joint. Methods We selected 2 periods of 1 year, before (n=98patients) and after ERAS implementation (n=92patients). Data were collected on patient demographics, operative and perioperative details, LOS, VAS score, Harris score, and 30-day complications. ERAS-trained nurses are engaged to support patients at each step of the pre/per/postoperative process, including completing a satisfaction survey, with the help of a mobile app. PS analyses were used for dealing with confounding bias in this retrospective observational study. Results After PS matching, the outcomes of 124 well-balanced pairs of patients were compared (conventional vs ERAS). LOS was significantly reduced from 24.3±3.9 to 15.2±2.9 days (P<0.001). With the same preoperative VAS scores, we found that patients in the ERAS group had significantly lower postoperative VAS scores than those in the conventional group at days 3 and 7 (P<0.001), but the difference was not statistically significant at day 14. patients in the ERAS group had higher Harris scores than those in the conventional group at 1 and 3 months, but the difference was not significant at 6 months. In addition, we found that only one patient in the ERAS group developed complications, while nine patients in the conventional group developed different complications. There was no significant difference concerning the satisfaction survey. Conclusion The introduction of ERAS for ITF in our institution has resulted in a significant decrease in LOS, alleviated patient pain, promoted early recovery of patient’s hip function while effectively preventing complications, and obtained patient satisfaction.
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Affiliation(s)
- Wenhao Zhu
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yinjie Yan
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yijin Sun
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Shanghai Jiao Tong University, Affiliated Shanghai Sixth People's Hospital, Shanghai, China
| | - Zhaoxiang Fan
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Niangkang Fang
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yunlu Zhang
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengchen Yin
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongbo Wan
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wen Mo
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wei Lu
- Shanghai University of Traditional Chinese Medicine, Shanghai, China. .,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Xuequn Wu
- Shanghai University of Traditional Chinese Medicine, Shanghai, China. .,LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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35
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Epstein N. Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities. Surg Neurol Int 2021; 12:349. [PMID: 34345489 PMCID: PMC8326133 DOI: 10.25259/sni_509_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nancy Epstein
- Clinical Prof. of Neurosurgery, School of Medicine, State University of New York at Stony Brook, NY, and c/o Dr. Marc Aglulnick, 1122 Franklin Avenue Suite 106, Garden City, NY, USA
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36
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Cifarelli CP, McMichael JP, Forman AG, Mihm PA, Cifarelli DT, Lee MR, Marsh W. Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures. Cureus 2021; 13:e16259. [PMID: 34277303 PMCID: PMC8269978 DOI: 10.7759/cureus.16259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/28/2022] Open
Abstract
Background Hospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS. Methods Retrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student’s t-test. Results 9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges. Conclusion Optimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures.
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Affiliation(s)
- Christopher P Cifarelli
- Neurological Surgery, West Virginia University School of Medicine, Morgantown, USA.,Radiation Oncology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Alex G Forman
- Strategic Analytics, West Virginia University School of Medicine, Morgantown, USA
| | - Paul A Mihm
- Surgical Services, West Virginia University School of Medicine, Morgantown, USA
| | - Daniel T Cifarelli
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Mark R Lee
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Wallis Marsh
- Surgery, West Virginia University School of Medicine, Morgantown, USA
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37
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Mulcahy MJ, Elalingam T, Jang K, D'Souza M, Tait M. Bilateral cervical plexus block for anterior cervical spine surgery: study protocol for a randomised placebo-controlled trial. Trials 2021; 22:424. [PMID: 34187541 PMCID: PMC8244165 DOI: 10.1186/s13063-021-05377-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 06/15/2021] [Indexed: 11/28/2022] Open
Abstract
Background There has been increasing focus to improve the quality of recovery following anterior cervical spine surgery (ACSS). Postoperative pain and nausea are the most common reasons for prolonged hospital stay and readmission after ACSS. Superficial cervical plexus block (SCPB) provides site-specific analgesia with minimal side effects, thereby improving the quality of recovery. The aim of our study was to investigate the effect bilateral cervical plexus block has on postoperative recovery in patients undergoing ACSS. Methods The study is a pragmatic, multi-centre, blinded, parallel-group, randomised placebo-controlled trial. 136 eligible patients (68 in each group) undergoing ACSS will be included. Patients randomised to the intervention group will have a SCPB administered under ultrasound guidance with a local anaesthetic solution (0.2% ropivacaine, 15mL); patients randomised to the placebo group will be injected in an identical manner with a saline solution. The primary outcome is the 40-item quality of recovery questionnaire score at 24 h after surgery. In addition, comparisons between groups will be made for a 24-h opioid usage and length of hospital stay. Neck pain intensity will be quantified using the numeric rating scale at 1, 3, 6 and at 24 h postoperatively. Incidence of nausea, vomiting, dysphagia or hoarseness in the first 24 h after surgery will also be measured. Discussion By conducting a blinded placebo trial, we aim to control for the bias inherently associated with a tangible medical intervention and show the true treatment effect of SCPB in ACSS. A statistically significant result will indicate an overall improved quality of recovery for patients; alternatively, if no benefit is shown, this trial will provide evidence that this intervention is unnecessary. Trial registration ClinicalTrials.gov ACTRN12619000028101. Prospectively registered on 11 January 2019 with Australia New Zealand Clinical Trials Registry
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Affiliation(s)
- Michael J Mulcahy
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia. .,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia.
| | - Thananchayan Elalingam
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Kevin Jang
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia
| | - Mario D'Souza
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Matthew Tait
- Department of Neurosurgery, Nepean Public Hospital, Sydney, Australia.,Macquarie Neurosurgery, Suite 201, 2 Technology Place, Sydney, Australia
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Jenkins NW, Parrish JM, Nolte MT, Jadczak CN, Mohan S, Geoghegan CE, Hrynewycz NM, Podnar J, Buvanendran A, Singh K. Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting. Int J Spine Surg 2021; 15:219-227. [PMID: 33900978 DOI: 10.14444/8030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol. METHODS A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered. RESULTS A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day. CONCLUSION In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.
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Affiliation(s)
- Nathaniel W Jenkins
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - James M Parrish
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Michael T Nolte
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Caroline N Jadczak
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Shruthi Mohan
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
| | - Jeffrey Podnar
- Department of Anesthesiology, Midwest Anesthesia Partners LLC, Park Ridge, Illinois
| | | | - Kern Singh
- Department of Orthopaedic Surgery, , Rush University Medical Center, Chicago, Illinois
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Mikhail CM, Echt M, Selverian SR, Cho SK. Recoup From Home? Comparison of Relative Cost Savings for ACDF, Lumbar Discectomy, and Short Segment Fusion Performed in the Inpatient Versus Outpatient Setting. Global Spine J 2021; 11:56S-65S. [PMID: 33890802 PMCID: PMC8076805 DOI: 10.1177/2192568220968772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on the cost efficacy of performing ACDF, lumbar discectomy and short segment fusions of the lumbar spine performed in the outpatient setting. METHODS A thorough review of peer- reviewed literature was performed on the relative cost-savings, as well as guidelines, outcomes, and indications for successfully implementing outpatient protocols for routine spine procedures. RESULTS Primary elective 1-2 level ACDF can be safely performed in most patient populations with a higher patient satisfaction rate and no significant difference in 90-day reoperations and readmission rates, and a savings of 4000 to 41 305 USD per case. Lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper by as much as 12 934 USD per case and has better or equivalent outcomes to their inpatient counterparts. Unlike ACDF and lumbar microdiscectomy, short segment fusions are rarely performed in ASCs. However, with the advent of minimally invasive techniques paired with improved pain control, same-day discharge after lumbar fusion has limited clinical data but appears to have potential cost-savings up to 65-70% by reducing admissions. CONCLUSION Performing ACDF, lumbar discectomy and short segment fusions in the outpatient setting is a safe and effective way of reducing cost in select patient populations.
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Affiliation(s)
- Christopher M. Mikhail
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stephen R. Selverian
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, MD, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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40
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Are outpatient three- and four-level anterior cervical discectomies and fusion safe? Spine J 2021; 21:231-238. [PMID: 33049410 DOI: 10.1016/j.spinee.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSE The present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGN Retrospective cohort study PATIENT SAMPLE: The National Surgical Quality Improvement Program - a large, prospectively-collected registry - was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURES The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODS Baseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTS In total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONS This present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.
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Marrache M, Harris AB, Puvanesarajah V, Raad M, Hassanzadeh H, Riley LH, Skolasky RL, Bicket M, Jain A. Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology. Global Spine J 2021; 11:108-115. [PMID: 32875850 PMCID: PMC7734273 DOI: 10.1177/2192568219899340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
STUDY DESIGN Retrospective review of an administrative database. OBJECTIVES The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology. METHODS Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission. RESULTS In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001. CONCLUSION Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.
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Affiliation(s)
| | | | | | - Micheal Raad
- The Johns Hopkins University, Baltimore, MD, USA
| | | | - Lee H. Riley
- The Johns Hopkins University, Baltimore, MD, USA
| | | | - Mark Bicket
- The Johns Hopkins University, Baltimore, MD, USA
| | - Amit Jain
- The Johns Hopkins University, Baltimore, MD, USA,Amit Jain, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, JHOC 5223, Baltimore, MD 21287, USA.
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Can Pediatric Orthopaedic Surgery be Done Safely in a Freestanding Ambulatory Surgery Center? Review of 3780 Cases. J Pediatr Orthop 2021; 41:e85-e89. [PMID: 32852367 DOI: 10.1097/bpo.0000000000001670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to determine the intraoperative and 30-day postoperative complication rates in a large consecutive cohort of pediatric patients who had orthopaedic surgery at a freestanding ambulatory surgery center (ASC). The authors also wanted to identify the rates of same-day, urgent hospital transfers, and 30-day hospital admissions. The authors hypothesized that pediatric orthopaedic procedures at a freestanding ASC can be done safely with a low rate of complications. METHODS A retrospective review identified patients aged 17 years or younger who had surgery at a freestanding ASC over a 9-year period. Adverse outcomes were divided into intraoperative complications, postoperative complications, need for the secondary procedure, unexpected hospital admission on the same day of the procedure, and unexpected hospital admission within 30 days of the index procedure. Complications were graded as grade 1, the complication could be treated without additional surgery or hospitalization; grade 2, the complication resulted in an unplanned return to the operating room (OR) or hospital admission; or grade 3, the complication resulted in an unplanned return to the OR or hospitalization with a change in the overall treatment plan. RESULTS Adequate follow-up was available for 3780 (86.1%) surgical procedures. Overall, there were 9 (0.24%) intraoperative complications, 2 (0.08%) urgent hospital transfers, 114 (3%) complications, and 16 (0.42%) readmissions. Seven of the 9 intraoperative complications resolved before leaving the OR, and 2 required return to the OR.Neither complications nor hospitalizations correlated with age, race, gender, or length or type of surgery. There was no correlation between the presence of medical comorbidities, body mass index, or American Society of Anesthesiologists score and complication or hospitalization. CONCLUSIONS Pediatric orthopaedic surgical procedures can be performed safely in an ASC because of multiple factors that include dedicated surgical teams, single-purpose ORs, and strict preoperative screening criteria. The rates of an emergency hospital transfer, surgical complications, and 30-day readmission, even by stringent criteria, are lower than those reported for outpatient procedures performed in the hospital setting. LEVEL OF EVIDENCE Level IV-case series.
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Identifying the Most Appropriate ACDF Patients for an Ambulatory Surgery Center: A Pilot Study Using Inpatient and Outpatient Hospital Data. Clin Spine Surg 2020; 33:418-423. [PMID: 32235168 DOI: 10.1097/bsd.0000000000000967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Safaee MM, Chang D, Hillman JM, Shah SS, Wadhwa H, Ames CP, Clark AJ. Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers. World Neurosurg 2020; 146:e940-e946. [PMID: 33217594 DOI: 10.1016/j.wneu.2020.11.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. OBJECTIVE To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. METHODS ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. RESULTS A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). CONCLUSION Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - John M Hillman
- Adult Business Line Finance, University of California Medical Center, San Francisco, California, USA
| | - Sumedh S Shah
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Harsh Wadhwa
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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Lopez CD, Boddapati V, Lombardi JM, Sardar ZM, Dyrszka MD, Lehman RA, Riew KD. Recent trends in medicare utilization and reimbursement for anterior cervical discectomy and fusion. Spine J 2020; 20:1737-1743. [PMID: 32562771 DOI: 10.1016/j.spinee.2020.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure. PURPOSE This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates. STUDY DESIGN/SETTING Retrospective analysis of patients undergoing ACDF PATIENT SAMPLE: Medicare patients undergoing ACDF between 2012 and 2017 OUTCOME MEASURES: ACDF volume, utilization rates, and surgeon/hospital reimbursement rates METHODS: This study tracked annual Medicare claims and payments to ACDF 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 variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates. RESULTS A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001). CONCLUSIONS While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.
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Affiliation(s)
- Cesar D Lopez
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY.
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Zeeshan M Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Marc D Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - K Daniel Riew
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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CuÉllar JM, Wagner W, Rasouli A. Low Complication Rate of Anterior Lumbar Spine Surgery in an Ambulatory Surgery Center. Int J Spine Surg 2020; 14:687-693. [PMID: 33097579 DOI: 10.14444/7100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND As healthcare costs rise, attempts are being made to perform an increasing proportion of spine surgery in ambulatory surgery centers (ASCs). ASCs are more efficient, both economically and functionally. There remains uncertainty regarding the safety of performing anterior lumbar procedures requiring vascular access, as little has been published on this subset of patients. METHODS This is a consecutive case series analysis of anterior lumbar spine surgeries that were performed in a free-standing ASC in a private-practice setting over a 1-year period, including anterior lumbar interbody fusion, artificial disc replacement, and hybrid procedures. The preoperative, intraoperative, and postoperative data recorded included age, gender, body mass index, tobacco use, and the presence of diabetes; level and procedure, operating room time, estimated blood loss, complications; discharge site, occurrence of reoperation, hospital admission, or any medical complication or infection over a 90-day period. RESULTS Fifty-one patients underwent 63 treated levels (34 artificial disc replacement, 29 anterior lumbar interbody fusion): 40 single-level, 10 two-level, one three-level. Average age was 45 years; 27 female, 24 males. None of the patients were diabetics, three were current smokers, seven were former smokers. Average body mass index was 27 ± 4 (range 16-36). Average total anesthesia time was 100 minutes (range 57-187 minutes). Average estimated blood loss was 23 mL (range 5-250 mL). Seventy-one percent of patients were discharged directly home, 29% to an aftercare facility. In the 30-day postoperative period there were no deaths, one hospital admission for pain, and no significant medical complications or surgical site infections. CONCLUSION In this consecutive case series artificial disc replacement or anterior lumbar interbody fusion was performed at 63 levels in 51 patients in the ASC setting with an observed major complication rate of zero and hospital unplanned admission rate of 2% (1/51). This provides some evidence that these procedures are safe to perform in the ASC setting. However, a highly experienced vascular surgeon and efficient surgical team, and strict patient selection criteria are all critical in making this possible.
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Affiliation(s)
- Jason M CuÉllar
- Cedars-Sinai Spine Center.,Department of Orthopaedic Surgery
| | - Willis Wagner
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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de Bree K, Atsma F, van Lindert EJ, Westert GP, Bartels RMHA. Need for post-operative outpatient appointments after discharge following cervical spinal surgery - a narrative review. BMC Musculoskelet Disord 2020; 21:614. [PMID: 32933488 PMCID: PMC7491072 DOI: 10.1186/s12891-020-03624-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the Netherlands most patients are currently seen in an outpatient clinic after an anterior cervical discectomy, which is an effective neurosurgical procedure with relatively low rate of severe complications. In this back sight, the need for patients returning to the post-operative outpatient clinic could be questioned. The aim of the study is to evaluate whether a post-operative outpatient appointment after anterior cervical discectomy could be replaced by an alternative or be omitted without adversely impacting, or increasing, the value of healthcare and patient satisfaction for this procedure. METHODS A narrative review was performed to evaluate the quality of care and patient satisfaction for patients with and without a post-operative outpatient appointment after spinal surgery. A literature search of the previous ten years was performed in Pubmed, CENTRAL and EMBASE. RESULTS A total of 403 articles were identified. Four studies remained after title and abstract selection by 3 independent reviewers. No papers were selected for further analysis, due to the absence of interventional studies that compared the utility of a post-operative outpatient clinic appointment with an intervention after spinal surgery. CONCLUSIONS Currently, there is a lack of evidence for the need of a post-operative follow-up after anterior cervical discectomy. Nor is there any literature in favor of omitting these appointments. No determinants which patients benefits from these outpatient appointments could be identified. Potential harmful and beneficial effects of omitting these post-operative follow-ups should be investigated to identify possible determinant for patients who might benefit from a post-operative appointment.
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Affiliation(s)
- Karel de Bree
- Department of Neurosurgery, Institute for Health Sciences, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, Nijmegen, 6500 HB, The Netherlands.
| | - Femke Atsma
- Scientific Center for Quality of Healthcare, Institute for Health Sciences, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein 21, Nijmegen, 6500 HB, The Netherlands
| | - Erik J van Lindert
- Department of Neurosurgery, Institute for Health Sciences, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, Nijmegen, 6500 HB, The Netherlands
| | - Gert P Westert
- Scientific Center for Quality of Healthcare, Institute for Health Sciences, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein 21, Nijmegen, 6500 HB, The Netherlands
| | - Ronald M H A Bartels
- Department of Neurosurgery, Institute for Health Sciences, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, Nijmegen, 6500 HB, The Netherlands
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Wang X, Meng Y, Liu H, Hong Y, Wang B. Comparison of the safety of outpatient cervical disc replacement with inpatient cervical disc replacement: A protocol for a meta-analysis. Medicine (Baltimore) 2020; 99:e21609. [PMID: 32871877 PMCID: PMC7458200 DOI: 10.1097/md.0000000000021609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cervical disc replacement (CDR) has been widely used as an effective treatment for cervical degenerative disc diseases in recent years. However, the cost of this procedure is very high and may bring a great economic burden to patients and the health care system. It is reported that outpatient procedures can reduce nearly 30% of the costs associated with hospitalization compared with inpatient procedures. However, the safety profile surrounding outpatient CDR remains poorly resolved. This study aims to evaluate the current evidence on the safety of outpatient CDR METHODS:: Four English databases were searched. The inclusion and exclusion criteria were developed according to the PICOS principle. The titles and abstracts of the records will be screened by 2 authors independently. Records that meet the eligibility criteria will be screened for a second time by reading the full text. An extraction form will be established for data extraction. Risk of bias assessment will be performed by 2 authors independently using Cochrane risk of bias tool or Newcastle-Ottawa scale. Data synthesis will be conducted using Stata software. Heterogeneity among studies will be assessed using I test. The funnel plot, Egger regression test, and Begg rank correlation test will be used to examine the publication bias. RESULTS The results of this meta-analysis will be published in a peer-review journal. CONCLUSION This will be the first meta-analysis that compares the safety of outpatient CDR with inpatient CDR. Our study will help surgeons fully understand the complications and safety profile surrounding outpatient CDR. OSF REGISTRATION NUMBER:: doi.org/10.17605/OSF.IO/3597Z.
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Affiliation(s)
- Xiaofei Wang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Yang Meng
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Hao Liu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Ying Hong
- Department of Anesthesia and Operation Center, West China Hospital, Sichuan University, Sichuan, China
- West China School of Nursing, Sichuan University, Sichuan, China
| | - Beiyu Wang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, Sichuan, China
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Yerneni K, Burke JF, Chunduru P, Molinaro AM, Riew KD, Traynelis VC, Tan LA. Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 86:30-45. [PMID: 30690479 DOI: 10.1093/neuros/nyy636] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 01/06/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined. OBJECTIVE To review the medical literature on the safety of outpatient ACDF. METHODS We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups. RESULTS We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001). CONCLUSION Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - John F Burke
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Pranathi Chunduru
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - K Daniel Riew
- The Daniel and Jane Och Spine Hospital, Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Vincent C Traynelis
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
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Lee R, Lee D, Iweala U, Ramamurti P, Weinreb JH, O’Brien JR. Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy. J Clin Orthop Trauma 2020; 15:161-167. [PMID: 33717932 PMCID: PMC7920123 DOI: 10.1016/j.jcot.2020.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/14/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy. METHODS 14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer's Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts. RESULTS Upon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%). CONCLUSION ACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF's for myelopathy in comparison to their inpatient counterparts. Performing ACDF's for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.
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Affiliation(s)
- Ryan Lee
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA,Corresponding author. The George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC, 20037, USA.
| | - Danny Lee
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Uchechi Iweala
- Division of Spine Surgery, New York University Langone Orthopaedic Hospital in New York, NY, USA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Jeffrey H. Weinreb
- Department of Orthopaedic Surgery, The George Washington University in Washington, DC, USA
| | - Joseph R. O’Brien
- Washington Spine and Scoliosis Clinic, OrthoBethesda in Bethesda, MD, USA
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