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Madsen HJ, Henderson WG, Dyas AR, Bronsert MR, Colborn KL, Lambert-Kerzner A, Meguid RA. Inpatient Versus Outpatient Surgery: A Comparison of Postoperative Mortality and Morbidity in Elective Operations. World J Surg 2023; 47:627-639. [PMID: 36380104 DOI: 10.1007/s00268-022-06819-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Operations performed outpatient offer several benefits. The prevalence of outpatient operations is growing. Consequently, the proportion of patients with multiple comorbidities undergoing outpatient surgery is increasing. We compared 30-day mortality and overall morbidity between outpatient and inpatient elective operations. METHODS Using the 2005-2018 ACS-NSQIP database, we evaluated trends in percent of hospital outpatient operations performed over time, and the percent of operations done outpatient versus inpatient by CPT code. Patient characteristics were compared for outpatient versus inpatient operations. We compared unadjusted and risk-adjusted 30-day mortality and morbidity for inpatient and outpatient operations. RESULTS A total of 6,494,298 patients were included. The proportion of outpatient operations increased over time, from 37.8% in 2005 to 48.2% in 2018. We analyzed the 50 most frequent operations performed outpatient versus inpatient 25-75% of the time (n = 1,743,097). Patients having outpatient operations were younger (51.6 vs 54.6 years), female (70.3% vs 67.3%), had fewer comorbidities, and lower ASA class (I-II, 69.3% vs. 59.9%). On both unadjusted and risk-adjusted analysis, 30-day mortality and overall morbidity were less likely in outpatient versus inpatient operations. CONCLUSION In this large multi-specialty analysis, we found that patients undergoing outpatient surgery had lower risk of 30-day morbidity and mortality than those undergoing the same inpatient operation. Patients having outpatient surgery were generally healthier, suggesting careful patient selection occurred even with increasing outpatient operation frequency. Patients and providers can feel reassured that outpatient operations are a safe, reasonable option for selected patients.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA. .,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, 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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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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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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Matsumoto T, Yamashita T, Okuda S, Maeno T, Nagamoto Y, Iwasaki M. A Detailed Clinical Course Leading to Hypoxic Ischemic Encephalopathy After Anterior Cervical Spine Surgery: A Case Report. JBJS Case Connect 2020; 10:e2000236. [PMID: 32910593 DOI: 10.2106/jbjs.cc.20.00236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 48-year-old woman underwent anterior cervical discectomy and fusion at C5/6. Extubation was performed immediately after surgery. Tachycardia, limb tremor, and panic attack developed approximately 4 hours after surgery at 16:15. Thirty minutes later, cessation of respiration occurred at 16:50. An experienced anesthesiologist attempted intubation but was unsuccessful because of laryngopharyngeal edema at the C2 level. Finally, an otolaryngologist performed tracheotomy and secured the airway at 17:20 but hypoxic encephalopathy ensued. CONCLUSION Predicting the airway obstruction caused by laryngopharyngeal edema was very difficult; hence, to prevent critical complications, systematic perioperative management is essential in anterior cervical spine surgery.
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Affiliation(s)
- Tomiya Matsumoto
- 1Department of Orthopaedic Surgery, Osaka Rosai Hospital, Osaka, Japan 2Department of Orthopaedic Surgery, Osaka National Hospital, Osaka, Japan 3Department of Orthopaedic Surgery, Ishikiri Seiki Hospital, Osaka, Japan
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Miccoli G, La Corte E, Pasquini E, Palandri G. Life-threatening delayed arterial hemorrhage following anterior cervical spine surgery: A case report and literature review. Surg Neurol Int 2020; 11:124. [PMID: 32494399 PMCID: PMC7265467 DOI: 10.25259/sni_225_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 11/04/2022] Open
Abstract
Background One of the most serious and potentially life-threatening adverse events associated with anterior cervical spine surgery is postoperative hematoma with acute airway obstruction. The causes of unpredicted delayed bleeding are, however, not fully elucidated. Here, we report a case of delayed arterial bleeding and sudden airway obstruction following a two-level ACDF. Case Description A 52-year-old male presented with the right paracentral disc herniations at the C4-C5 and C5-C6 levels. A two-level ACDF was performed. Notably, on the 5th postoperative day, the patient developed an acute respiratory distress due to a large right lateral retrotracheal hematoma requiring emergency evacuation at the bedside. This was followed by formal ligation of a branch of the right superior thyroid artery in the operating room. In addition, an emergency tracheotomy was performed. By postoperative day 15, the tracheotomy was removed, and the patient was neurologically intact. Conclusion A superior thyroid artery hemorrhage should be suspected if a patient develops delayed neck swelling with or without respiratory decompensation several days to weeks following an ACDF. Notably, these hematomas should be immediately recognized and treated (i.e., decompression starting at the bedside and completed in the operating room) to prevent catastrophic morbidity or mortality.
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Affiliation(s)
- Giovanni Miccoli
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Via Sergio Pansini, Naples, Bologna, Italy
| | - Emanuele La Corte
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Department of Neurological Surgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Giorgio Palandri
- Department of Neurological Surgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Sheha ED, Derman PB. Complication avoidance and management in ambulatory spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S181-S190. [PMID: 31656873 DOI: 10.21037/jss.2019.08.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The positive safety profile and potential cost savings associated with ambulatory spine surgery have resulted in an increasing number of spine procedures being performed on an outpatient basis. As indications become more inclusive and the variety and volume of ambulatory procedures grow, the incidence of complications may rise. Limiting adverse events in the outpatient setting starts with patient selection. Surgeons should be aware of the potential complications and associated risk factors for common ambulatory spine procedures and employ strategies to limit and appropriately manage them. Protocols which include patient education, multimodal anesthesia and analgesia, standardized post-operative monitoring, and safe discharge planning are also essential for maximizing safety in the ambulatory setting.
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