With the growth of outpatient orthopedic spine surgery, more research is warranted

As the potential and practicality of orthopedic spine surgery performed in the outpatient setting gains traction with both patients and surgeons, questions still remain about reimbursement, risk-to-benefit ratios, guidelines for follow-up care and decisions about which procedures should be done in this environment.

“The question for spinal surgery is what are the appropriate kinds of procedures to be done in an ambulatory setting and which ones are best suited to be done in a hospital?” Andrew C. Hecht, MD, chief of spine surgery and associate professor in orthopedics and neurosurgery at Mount Sinai Hospital in New York City, told Orthopedics Today. “Some ambulatory centers allow for an observation status overnight. Also, some ambulatory surgery centers [ASCs] are either next to a hospital and have a relationship with them so that if someone needed to stay longer they could, but some do not have this relationship.”

According to Kern Singh, MD, associate director in the Department of Orthopedic Surgery at Rush University Medical Center and co-director of the Minimally Invasive Spine Institute at Rush, two aspects that are driving more outpatient spine surgery include the high patient demand for a quick return to function and the need for lower costs among spine surgery procedures.

 

“From a patient-driven perspective, patients are demanding a return to function sooner,” Singh told Orthopedics Today. “It is more outpatient in that we can do the same procedure in a much more cost contained fashion. As we move to a more global health care delivery system, it is important for us to reduce costs and hospitals are much more expensive than surgery centers.”

Another benefit to outpatient orthopedic spine surgery is that patients are able to go home the same day.

“Assuming the surgery is something that is reasonably suited to the outpatient setting and the patient is able to go home in relative comfort and their family is able to manage postoperatively as necessary, the patient probably has the benefit of being in comfortable surroundings with family and friends to help them,” John G. Heller, MD, Baur professor of orthopedic surgery and spine fellowship director for the Emory Spine Center, told Orthopedics Today.

Other benefits include a lower risk of infection and more personalized care for the patient, as well as the possibility of decreased time commitment from staff and physicians and less financial obligation for the hospital administration if a patient is discharged home.

In comparison, inpatient surgery has the benefit of a longer patient observation period in case there are any postoperative complications. However, this is tempered by the risk of nosocomial complications that can occur from being in the hospital, such an increased infection risk. Some surgeons also noted that patients who have spine surgery in the hospital setting may be provided more narcotics and sedative medications leading them to not mobilize as quickly as those in an outpatient setting.

“There is no 100% zero risk solution and so [surgeons are] trying to weigh the benefit of observation under the care of a physician and nursing staff against the potential of a nosocomial complication,” Christopher T. Martin, MD, resident physician at the University of Iowa, told Orthopedics Today.

“For patients the question is, ‘Is there a benefit to 24-hour observation period for these smaller cases?’” Martin said. “For a small, less invasive procedure, is it safe to go home the same day or is there some benefit to a period of observation under the care of a physician and nursing staff?”

Many surgeons believe it is safe for patients to go home after an outpatient, minimally invasive surgery. However, certain procedures can still carry a small, but finite, risk of serious complications. For example, surgery on the lumbar spine can lead to an expanding hematoma, as well as some pressure on the neurologic elements that would need an urgent debridement or decompression. Surgery on the cervical spine can also present similar hematoma that could compress the patient’s airway.

“One of the downsides is that once a patient gets in the car and drives home, there is nobody to help them except family and friends,” Heller said. “If they start having problems with nausea and vomiting; if they have a reaction to their pain medicine; if they, for some reason, cannot urinate; or if they have one of the low frequency but very impactful complications of a spine procedure, they are at home. They are not at the hospital where time is of the essence and there are people trained to help address the situation.”

Optimal procedures

Orthopedic surgeons interviewed by Orthopedics Today noted that while minimally invasive orthopedic spine procedures are generally acceptable to be performed in the outpatient setting, the jury is still out on whether lumbar and cervical spine surgeries should be performed in ASCs.

“Primarily doing single-level, small procedures through small incisions tend to carry fairly low risks of postoperative complications and if the risk of postoperative complications is low, there may not be any benefit to coming into the hospital for a period of observation,” Martin said. “Certainly, no one is advocating outpatient surgery for multilevel procedures or high-risk procedures.”

Many sources noted it is important for all spine surgeries to be labeled as either appropriate or inappropriate for outpatient surgery, as well as what complications could occur and which patients are at high risk for these complications.

“Where cases above a certain level of complexity should probably be done in a hospital vs. being done in an ambulatory surgery center remains to be clarified,” Hecht said. “There are a lot of decisions that factor into it, including the overall health of the patient and the other medical comorbidities the patient has. There are a lot of variables like that that factor into the decision, but I think each decision should be based on what is in the best interest of the patient rather than any financial interests.”

Ethical dilemmas

Weighing the risks and benefits of outpatient orthopedic spine surgery can lead to dilemmas about patient care such as, how long patients should be observed after surgery. Surgeons need to decide whether a patient has a high risk for complication after outpatient spine surgery, and if so, surgeons need to weigh it against the complications that could occur in an inpatient setting.

“Ahead of time, [the surgeon] cannot know for certain which patients are going to have complications. We try to look at which patients have the highest risk for having a negative outcome and then, if there is a high risk patient, it may be more reasonable to admit and observe that patient,” Martin said. “Those are the choices and compromises: the risk of a nosocomial complication with being admitted vs. the risk of postoperative event that would not be identified quickly enough if you were discharged home right away.”

If an ASC is associated with a hospital or has room to house a few patients, it may be beneficial for patients to stay for a few hours of observation after outpatient surgery — especially if the patient is at risk for complications. However, surgeons should make it clear to patients that even in outpatient surgery, there will still be a few hours where the patient will need to stay for observation.

“Same day discharge or outpatient surgery does not necessarily mean no period of observation,” Martin said. “Many times if a surgeon is doing an outpatient surgery, the surgeon will book that case as the first case of the day. Maybe that case takes a couple of hours, the patient is in a recovery room for a period of 4 hours to 6 hours and then goes home in the early afternoon. It may be if [a patient undergoes] outpatient surgery there is still a period of short-term observation under the care of a physician and nursing staff. It is not like [the patient] comes out of the operating room and goes home instantly.”

Another ethical dilemma can arise when surgeons performing the spine procedures have financial interests in an ASC to which they are referring patients. A study published in the Global Spine Journal by Hecht and colleagues showed 49.1% of surgeons who performed ambulatory spine surgery were also investors in the ASCs. According to the researchers, the surgeon’s investment in the ASC may play a role in whether to perform outpatient spine procedures in the ambulatory setting vs. the hospital setting.

“I think the biggest ethical dilemma is that many surgeons that do surgery in ambulatory surgery centers are also investors or shareholders in the ambulatory surgery center,” Hecht said. “The key thing that we hope is that surgeons are making the decision about what is best for patients completely divested from financial incentives.”

Reimbursement issues

With limited reimbursement policies and fee schedules created for outpatient orthopedic spine surgery, such procedures have not been fully implemented in all outpatient environments.

“Most procedures are currently not reimbursed in the outpatient environment in spine, the reason being because technology has never allowed outpatient spinal surgery to occur,” Singh said. “Now that we have the technology, we are trying to get the reimbursement to get caught up. We are doing the exact same procedure that we are doing in the inpatient environment. So it would make sense that we should be getting paid at a similar rate of outpatient, which is typically cheaper for both the payer, the facility and the patient. It is more of a challenge of educating the insurers that it is the same procedure at a lower cost and the rates should be similar.”

Recently, CMS included 10 new spine procedures to the 2015 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Policy Changes and Payment rules. Over a number of years, CMS has reduced the surgical fees for many of these codes, which, according to David A. Wong, MD, MSc, FRCS, an orthopedic spine surgeon at Denver Spine Surgeons, is causing concerns for surgeons. Some of the procedures CMS added included higher frequency codes for decompression and small fusion procedures which CMS has targeted in the past, Wong said.

“The big concern is that CMS is going to use shifting those procedures onto the outpatient list as an excuse to try to reduce the reimbursement even further; whereas, clearly, what we are doing inpatient or outpatient, is essentially the same surgical procedure,” Wong told Orthopedics Today.

He also noted that CMS has on previous occasions rolled the day of surgery admission evaluation, 120 days of postoperative care/office visits and use of an operating microscope during surgery into the global surgical fee.

“[The approved] procedures are reasonable to be done in an outpatient setting, but we have an issue in terms of waiting to see whether or not it becomes an impetus for CMS to reduce the reimbursement for the surgical procedure itself,” Wong said. “Even though [outpatient surgery] saves them money for procedures done minimally invasive with shorter stays in an outpatient setting rather than incur a full service hospital charge, [CMS] keeps ratcheting down the surgical fees for these common, high frequency procedures.”

According to David Glaser, JD, a health care attorney at Fredrikson & Byron, P.A., some insurance companies seem to be reluctant to cover outpatient spine surgery.

“One of the things I do not understand is there seems to be a reluctance of some private insurers to pay for services in the outpatient setting,” Glaser told Orthopedics Today. “There has been a lot of pushback where the insurers are saying they will not cover [spine surgery], there needs to be pre-approval, they will not cover it at all or some variance on that theme. Now, I do not think that is an inpatient vs. outpatient difference. I think that is just spine surgery generally.”

While there are a few payers interested in supporting outpatient spine surgery, most insurance companies are waiting for Medicare and CMS to create a fee schedule for outpatient surgery.

“Right now, only a few payers have jumped head first into [outpatient surgery]. Most have waited on the sideline with Medicare and the Centers for Medicare and Medicaid Services to come out with their own fee schedule,” Singh said.

For ASCs and outpatient centers interested in implementing outpatient spine surgery, it is important to review all payers to see which ones cover specific services.

“One of the important things before considering doing any procedure outpatient is to review every payer independently,” Glaser said. “Knowing what one payer will do is only useful for that one payer.”

Future of spine surgery

Many surgeons interviewed for this article can see minimally invasive outpatient orthopedic spine surgery becoming a more widely used procedure.

“Across the country, there is increasing emphasis on minimally invasive spine and on early hospital discharge,” Martin said. “I think that in the future there is going to be greater emphasis on those types of procedures and probably a greater occurrence of smaller cases with early or same day discharges.”

While there is still work to be done with finding which spine surgeries are best performed as outpatient procedures, more research will help guide surgeons.

“I suspect we will find a comfort zone where the comparative effectiveness of outpatient spine procedures for certain diagnoses makes sense and we will probably learn that for other diagnoses and procedures, it does not make sense,” Heller said. “Along the way, we will have more early adopters and conservative surgeons charting that landscape. Hopefully, we will have good information that comes back to us from the payer world that helps sort out the comparative effectiveness of it, because in the end, we want patients well-served.” – by Casey Tingle

Reference:

Baird EO. Global Spine J. 2014;doi:10.1055/s-0034-1378142.

For more information:

David Glaser, JD, can be reached at Fredrikson & Byron, 200 South Sixth St. #4000, Minneapolis, MN 55402; email: dglaser@fredlaw.com.
Andrew Hecht, MD, can be reached at Mount Sinai Hospital, 5 E 98th St., #9, New York, NY 10029; email: andrew.hecht@mountsinai.org
John G. Heller, MD, can be reached at the Emory Spine Center, 59 Executive Park S., Atlanta, GA 30329; email: jhell02@emory.edu.
Christopher T. Martin, MD, can be reached at the University of Iowa, Iowa City, Iowa 52242; email: christopher-t-martin@uiowa.edu.
Kern Singh, MD, can be reached at Rush University Medical Center, 1725 W. Harrison St., Chicago, IL 60612; email: kern.singh@rushortho.com.
David A. Wong, MD, MSc, FRCS, can be reached at Denver Spine Surgeons, 7800 East Orchard Rd. #100, Greenwood Village, CO 80111; email: ddaw@denverspinesurgeons.com.
Disclosure: Martin is an emeritus member of the publications committee for the American Academy of Orthopedics and received grant support from the Orthopaedic Rehabilitation Association, Orthopaedic Trauma Association and Iowa Orthopedic Society. Glaser, Hecht, Heller, Singh and Wong have no relevant financial disclosures.

Should orthopedic spine surgery be performed in an outpatient setting?

Practice supported by data and literature

Of course, outpatient spine surgery should be performed. For decades, certain spine surgeries have been safely and successfully performed in an outpatient setting. The advantages are myriad, from patient comfort to decreased infection rates. This trend has been driven mostly by patient demand. If you could go home after an operation, why would you want to spend the night in a hospital? The important question is, “Do we have data that supports allowing patients to go home the same day as their operation?” The answer is, we absolutely do.

Posterior lumbar microdiscectomy is the classic spine operation that is routinely performed on an outpatient basis. We have decades of data demonstrating the success and safety of microlumbar discectomy performed on an outpatient basis. In fact, in many areas of the United States, the standard of care is to perform lumbar microdiscectomy on an outpatient basis.

This concept of outpatient lumbar nerve root decompression has been successfully expanded to include stenosis operations in an older patient population. With meticulous preoperative planning and preparation, all types of lumbar radiculopathies can be decompressed with patients going home within 2 hours of their operation, even with extraforaminal pathology.

We now have more than 20 years of experience with performing anterior cervical discectomy and fusion (ACDF) as an outpatient procedure. I did my first ACDF with my patient going home 4 hours after the operation in 1993. There is now extensive literature documenting the safety of ACDF performed as outpatient surgery. Cervical arthroplasty and posterior laminoforaminotomy are also routinely completed on an outpatient basis currently. A systemic review of cervical spine surgery performed in an outpatient setting was recently published in the evidence-based Spine Care journal. This review of the literature did not find any increased risk of complications with outpatient surgery. In fact, the risk of infection was less in the outpatient population compared with the inpatient group.

There have been reports of one-level lumbar fusion procedures being performed as outpatients, but the vast majority of these are actually spending the night in the outpatient facility and are more accurately described as 23-hour stays. With continued advancements in technology, instrumentation, biologics, intraoperative navigation, and postoperative pain strategies, these procedures may, in the future, become routinely done as true outpatient operations.

With careful preoperative preparation and selection combined with meticulous technical surgical skill, outpatient spine surgery is routinely being performed. The literature supports continuing this practice by demonstrating that these outpatient spine procedures are being done safely and effectively. With technological advancements, it is likely that the types of spine procedures performed on an outpatient basis will increase.

Rick C. Sasso, MD, is a professor and chief of spine surgery at Indiana University School of Medicine and the Indiana Spine Group.
Disclosure: Sasso has no relevant financial disclosures.

References:

Best NM. J Spinal Disord Tech. 2006;19:334-337.
Best NM. Spine. 2007;32:1135-1139.
Garringer SM. J Spinal Disord Tech. 2010;doi:10.1097/BSD.0b013e3181bd0419.
Lee MJ. Evid Based Spine Care J. 2014;doi:10.1055/s-0034-1389088.Miller JW. SAS Journal. 2011;doi:10.1016/j.esas.2010.11.002
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Cautiously select patients

Ambulatory spine surgery has shown exponential growth since early descriptions from the mid-1980s. Early on, significant economic advantages became apparent, with almost four-fold cost differentials favoring outpatient surgery. Industry estimates project a 10-fold increase for ambulatory spine surgery between 2005 (27,559 cases) and 2015 (284,850 cases). This seems to be a steadily growing trend. Nevertheless, it is not completely clear how safe is ambulatory spine surgery. Two recent studies provide some conclusive answers.

In a recent National Surgical Quality Improvement Program study adjusting preoperative comorbidity differences with propensity-score matching, outpatient lumbar discectomy demonstrated overall lower perioperative complication rates than inpatients. In a similar study, single-level anterior cervical decompression and fusion (ACDF) also demonstrated comparable 30-day systemic morbidity rates between inpatients and outpatients. The reasons for this are unclear, but one may speculate that outpatients mobilize earlier, use less urinary catheterization and are less exposed to nosocomial pathogens.

Not all patients are appropriate candidates for outpatient procedures. In lumbar discectomies, advanced age (older than 70 years), diabetes, preoperative wound infection, prolonged surgical time (more than 150 minutes) and requirement for blood transfusions were independent risk factors for short-term complications. Similarly, in single-level ACDF, age (older than 65 years), obesity (BMI>30kg/m2), ASA class 3 or 4, dialysis, steroid use, recent sepsis and prolonged surgical times (more than 120 minutes) were independent risk factors for complications. These factors should aid surgeons in cautiously selecting patients for outpatient surgery. Finally, the effect of prolonged surgical time should caution the surgical team to strive for a quick and efficient surgical performance.

Sergio Mendoza-Lattes, MD, is from Duke University Medical Center.
Disclosure: Mendoza-Lattes is a consultant for Globus Medical.

References:

Martin CT. J Bone Joint Surg Am. 2014; doi:10.2106/JBJS.M.00767.
Newman MH. Spine. 1995;20:353-355.
NeuroSource. Top Trends in Neuroscience. 2005.
Pugely AJ. Spine. 2014;doi:10.1097/BRS.0000000000000270.
Zahrawi F. Spine. 1994;19:1070-1074.

ASCs can provide superior value for select procedures

For a select subset of spine surgery procedures, the ambulatory surgery center (ASC) environment provides superior value to the patient, surgeon and third party payer when compared to inpatient hospital settings. For nearly a decade, we at Carolina Neurosurgery & Spine Associates have performed anterior cervical fusion, cervical foraminotomy, lumbar micro discectomy, and lumbar laminectomy in the ASC setting at a cost of only 70% of the hospital environment. In a recent analysis presented at the Congress of Neurological Surgeons Annual Meeting, for every 1,000 ACDF surgeries performed in our ACS environment, we found that less than 1% of patients experienced perioperative morbidity; all of which were safely recognized and treated in the ASC environment. Furthermore, 1-year patient-reported outcomes demonstrated the ASC as equally safe and effective at providing health and quality-of-life benefit to patients, suggesting ASCs as cost-effective advancements, which will likely be rewarded in value-based reform.

ASCs represent a more efficient, cost-effective, and equally safe alternative to inpatient hospital settings for a select subset of spine surgery procedures.

Matthew J. McGirt, MD, is with Carolina Neurosurgery & Spine Associates and is an adjunct associate professor at the University of North Carolina.
Disclosure: McGirt has no relevant financial disclosures.