Risks of same-day spine surgery must be addressed as its popularity increases

Same-day spine surgery has become more prevalent in recent years with surgeons expanding the types of procedures they perform in ASCs. At the same time, concerns remain over risks with these procedures and how surgeon investment in these surgical centers may affect patient selection.

By 2025, same-day spine surgery could account for almost 50% of all spine surgeries done in the United States, Robert S. Bray Jr., MD, said. In 2007, he founded the DISC Sports & Spine Center, in Marina Del Rey, Calif., which is an ASC that offers a variety of spine surgeries performed in a single day.

“In less than 10 years, we will have more than 50% done in an outpatient setting,” he said, noting he refers to these as outpatient spine surgery cases since some patients are discharged the same day and others are discharged the following morning.

“We have to account for patient variables regardless of the case,” Bray said, noting key factors include the type of surgery, the patient (ie, their general health) and other variables that can be foreseen.

Bray said the reason there is growth in outpatient spine surgery is there is now enough of a track record to show it works.

“It is proven. It was in its baby stages 8 to 10 years ago, but now it is a rapidly growing institution and the centers are starting,” Bray told Spine Surgery Today

 

Bray said physicians at these centers start, appropriately, with easier cases. They then expand their infrastructures.

“You will see companies, like SCA [Surgical Care Affiliates, Deerfield, Ill.], that have very strong interest in expanding high-acuity centers for spine programs for select service lines. You will see service lines expand, and it is going to be a fairly significant transition in the next 10 years,” he said.

More popular approach

Bray has performed outpatient spine surgery for the last 12 years to 13 years, and his experience allows him to perform nearly any procedure in his outpatient surgical center. However, he said, spine surgeons should start with uncomplicated procedures when they first delve into performing same-day spine surgery.

Pain management, blocks, microdiscectomy and simple foraminotomy are good procedures for surgeons to begin with when they initially perform same-day surgery, Bray said. With added experience, they can increase the complexity of procedures they perform at an ASC, he noted.

“At this point, I do not have much of a limit. I do front and back reconstructions, pedicle screws, intervertebral tumors, vascular malformations. I do things you would never think of as being an outpatient case, and we do it very routinely. We have grown over time, but I will stand on the fact that I have never had one patient admitted to a hospital,” he said.

However, complications can occur in the ASC setting, just as they would in an operating room at a hospital.

Safety not guaranteed

Although many complications can be dealt with at an ASC, Michael J. Lee, MD, said there are rare and sometimes devastating complications that are associated with more complex procedures, such as anterior cervical discectomies.

He told Spine Surgery Today, “You need to take a patient profile into consideration when considering same-day surgery. A young, healthy 25-year-old will likely do very well; for a 65-year-old patient with multiple comorbidities, it is probably prudent to admit overnight for monitoring after anesthesia. It is not a one-size-fits-all scenario for each patient,” he said.

According to Lee, the safety of same-day spine surgery in an ASC depends on the type of surgery and the patient’s overall experience. The safety of same-day spine surgery and the outcomes are not the same for every patient. Therefore, a patient’s comorbidities should be the biggest driver when a surgeon determines whether a spine procedure will be safe for that patient when it is performed on a same-day basis.

Patient selection is key

Surgeons should be cautious when selecting patients for procedures performed in this setting, especially when a more complex procedure, such as an anterior cervical discectomy, is planned to be performed in an ASC, Lee said.

Most healthy patients who undergo anterior discectomy are admitted overnight for observation, he said. They will generally go home on postoperative day 1, and less commonly on day 2 or beyond.

“It is tempting to push this toward outpatient surgery — and the odds are that the vast majority of patients should do well — but, rarely, potentially devastating complications can still occur. If a patient develops a retropharyngeal hematoma after anterior-cervical spine surgery, which compromises the airway, timely medical attention is essential. The time it takes for a patient to obtain that medical attention can literally be the difference between life and death. If a patient has to travel from home to a facility, that additional time can have a huge effect on the patient’s outcome,” Lee said.

Such complications can be a problem as surgeons seek to complete more complicated and complex procedures in the outpatient setting, according to Andrew C. Hecht, MD, a Spine Surgery Today Editorial Board member.

More risks with investment

Hecht and colleagues assessed the practices and procedures of spine surgeons in an ASC in a study published in 2014, in which they surveyed members of the International Society for the Advancement of Spine Surgery regarding their experience with ambulatory spine surgery.

“The most common procedures people felt comfortable doing there were really lumbar microdiscectomy, a one- or two-level laminectomy, cervical foraminotomy, and one-or possibly two -level anterior cervical discectomy and fusions. There was a direct correlation between, unfortunately, the complexity of the case you were willing to do in an ASC and whether you were an investor in an ASC, which to me is a little disheartening,” Hecht said.

He told Spine Surgery Today the types of cases and the complexity of the cases done in ASCs should be considered regardless of whether there is any financial incentive relating to doing them, he said.

No plan in place

The study showed 92% of surgeons at ASCs had an emergency protocol in place if a complication arose that could not be addressed at the center. This meant 8% of those polled had no emergency protocol in place if that situation occurred.

“Surgeons have to ask themselves what is their facility set up to do. Can a complex surgery be managed in an ASC? If they are doing it there, why are they doing it there? If they are doing it for the betterment of the patient and their outcomes, that is an easy thing. If they are doing it for other reasons, that is a different thing. If you keep your focus on what is best for patients, you will usually get yourself going down the right pathway,” Hecht said.

Spine surgeons who operate at an ASC must keep their patients’ best interests in mind when they select patients for certain procedures. Same-day spine surgery does have a role within the field of spine surgery, but surgeons should reserve it for patients and procedures that can be comfortably and safely done at the ASC and that are technically feasible, according to Hecht. Therefore, the procedures best suited for same-day surgery are typically the ones that have reproducible outcomes and minimal complications, he said.

Pain management protocol

To ensure his same-day surgeries are safe and facilitate patient discharge within 24 hours of the procedure, Bray’s ASC uses a specific pain management system that helps patients ambulate more quickly, minimizes pain and sedation compared with in-patient procedures, and promotes mobility, he said.

“We have one nurse for one or two patients, at the most, and they micromanage their pain in the first few hours. They give frequent, tiny doses of pain medicines, often fentanyl, and we very early switch them to oral medicines,” Bray said. “We use a combination of anti-inflammatories, toradol IV (ketorolac), a muscle relaxant, and a PO medication given very early, and we get them mobilized very early. We use continuous cooling machines on everyone’s incisions, and the combination of that allows us to get them out of bed and walking in literally a few hours. We never really let them get into pain and have to sedate them to get out of pain.”

If a patient has a catheter, it is removed as quickly as possible after surgery. Patients are encouraged to become mobile and use the bathroom as soon as they are able which is typically within about 2 hours to 3 hours after the completion of their surgery according to Bray.

Depending on the complexity of the case and the patient’s medical condition, he said DISC has the capability of keeping patients overnight with a high level of intensive monitoring, and for complex procedures, this is part of the routine surgical experience.

Home nursing is available

Nurses manage the protocol after the surgery is completed, which includes educating the patient and family about what to expect after the patient is discharged from the ASC.

“It is a whole mentality you develop. In doing so, we have been able to tackle bigger and bigger cases over time. It has been a 10-year learning curve. But, we routinely go through the belly, flip the patient over, go through the back, put in pedicle screws and have them walking down the hallway 2 hours later. They do not get an ilius, their pain is managed and they go home,” Bray said.

If a patient requires extra care after they go home, the center where Bray works has a home nursing program that can send a nurse home with a patient after discharge. The nurse helps patients get settled at home, contacts their physician and, if needed, will check up on them during a shift the next day.

Cost savings are evident

In terms of economy, most ASCs have far fewer employees than a hospital and, therefore, the overhead is much less, according to Richard A. Kube II, MD.

“As far as patient satisfaction, patients tend to be more satisfied in an ambulatory center, more comfortable, more personable and satisfaction rates tend to be higher. We have the ability to do surgery safely, with good outcomes, [and] happier people. The last factor is the cost. We are able to beat cost on a pretty regular basis,” he told Spine Surgery Today.

Kube said his ASC is completely spine-based and has been able to cut out overhead, something that can increase the cost of a procedure at a hospital. Additionally, ASCs are able to procure the latest in cutting-edge technology without having to take up a request with a hospital board or committee to approve the purchase.

Bundle pricing is possible

In addition, an ASC can often provide a bundle pricing model for patients and insurance companies. Therefore, in Kube’s opinion, an ASC is more transparent in its pricing because there are far fewer departments or entities sending the insurance company or patient a bill after the procedure is completed.

“From an insurer standpoint, it is nice to be able to negotiate with a single individual rather than 50 individuals. It is nice for them to know what the price is and have a lot more transparency than they might at the hospital. You go to a hospital and there are so many other factors flowing around. You go and there is the hospital bill, the surgeon’s bill, but then you have the radiology department sending a bill, the pathology department sending a bill, obviously anesthesia, as well. You have a contracted rate. You talk to a surgeon who says ‘I am going to charge X, Y and Z,’ but there are eight other people who are sitting there adding to the bills, as well,” Kube said.

An ASC has a better cost profile compared with a hospital because it controls most of the factors going into a bill. Furthermore, it adds more value to the dollars a patient is spending, he noted.

Hospital created ASCs

Hospitals are also looking into providing outpatient spine services for patients, according to sources interviewed. Since patients are inquiring about outpatient spine surgery more often, it is a market worth looking into, according to Sanjit Mahanti, chief of business development and performance improvement officer at Keck Medicine of USC, in Los Angeles.

“As medicine and technology changes, as cost pressure becomes a bigger part of why we have to make decisions, doing the right case in the right place to deliver the best patient care and provide the best value to the patient, is going to be what gets rewarded in the future,” Mahanti said. “I think it is important to have that governing belief when looking at any new services in terms of where and how you want to start cultivating them,” he said.

The advent and continuing advances in minimally invasive surgery make outpatient spine procedures an interesting option, Mahanti noted. He said Keck Medicine of USC is planning to open an ASC that would allow the health system to offer patients more outpatient spine surgery options, but the cost structure and determination of what types of cases can be performed in such an ASC needs to still be determined.

An expensive venture

According to Mahanti, Keck Medicine of USC currently has an outpatient surgery center, but it would need to devote a considerable amount of money to equip and staff it to provide outpatient spine surgery services (same-day spine surgeries are currently performed in the hospital operating room).

“The risks are about the costs. If you do not get your arms around the finances early, you are going to be in trouble,” Mahanti told Spine Surgery Today. “It is not just volume that determines economic solvency in an outpatient setting anymore. The stuff has to make money and margins have to be correct from a cost standpoint. We are in the process of working with a team. It takes the spine surgeons talking with director of periop [perioperative], to price out the equipment. It is not a cheap service to start. We have an outpatient surgery center, but it is about the equipment and technology we would need. Spine is not cheap to start.”

Bray noted the protocol he uses can help beat the statistics of such postoperative complications as urinary tract infections, blood clots and pneumonia, which are common after lengthy hospital stays or when patients are on IV medications or pumps, and may prove more cost-effective. The patients are quickly switched to a narcotic regimen they can go home, and they are sedated for a shorter period of time, which has cost-savings implications, he said.

Understand the limitations

With outpatient spine surgery becoming more popular, Hecht said it is important for the ASC, as well as the surgeon performing a procedure in one of those centers, to understand the limitations of what can be performed safely in such a setting.

“There are definitely ways to perform ambulatory spine surgeries safely; the key thing is being clear about what can be performed safely in the given surgery center you are in. It may be possible to perform certain procedures more safely in an ASC than you would perform across the board. But, you have to have a protocol in place to manage complications and to manage untoward events, so to speak. If someone needs to stay over, if someone needs to be transported to the main hospital— whatever it is, you need a plan,” he said. – by Robert Linnehan

• Reference:
• Baird EO, et al. Global Spine J. 2014;doi:10.1055/s-0034-1378142.

• For more information:
• Robert S. Bray Jr., MD, can be reached at DISC Sports and Spine Center, 13160 Mindanao Way, #300, Marina Del Rey, CA 90292; email: gbray@discmdgroup.com.
• Andrew C. Hecht, MD, can be reached at Mt. Sinai Medical Center and Icahn School of Medicine, 5 East 98th St., 4th Floor, New York, NY 10029; email: andrew.hecht@mtsinai.org.
• Richard A. Kube II, MD, can be reached at Prairie Spine and Pain Institute, 7620 N. University St., #104, Peoria, IL 61614; email: rkube@prairiespine.com.
• Michael J. Lee, MD, can be reached at Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medical Center & Biological Sciences, 5801 S. Ellis Ave., Chicago, IL 60637; email: mlee5@bsd.uchicago.edu.
• Sanjit Mahanti can be reached at Keck Medicine of USC, 1510 San Pablo St., Los Angeles, CA 90033; email: sanjit.mahanti@med.usc.edu.

Disclosures: Bray, Hecht, Lee and Mahanti report no relevant financial disclosures. Kube owns the Prairie Spine and Pain Institute.

 

Should spine surgery be performed in the outpatient setting of a free-standing ASC not attached to a hospital?

A cost-effective solution

Overall health care expenditures will continue to increase with the aging of the population and the extension of health care coverage to previously uninsured groups. In recent years, government programs, private insurance companies, managed care organizations and self-insured employers have implemented various cost-containment measures to promote the delivery of health care services in the most cost-efficient setting. These cost-containment measures, together with technological advances, have resulted in a significant shift in the delivery of health care services away from traditional inpatient hospitals to more cost-effective alternate sites, including ASCs.

Historically, outpatient surgery centers have experienced favorable reimbursement due to an attractive mix of payers and cases. ASC revenue derived from Medicare and government pay is typically less than 30%, and the balance of approximately 70% is derived from private payers. In January 2002, outpatient surgery centers changed from a hybrid cost/charge-based reimbursement system to a prospective payment system for procedures covered by Medicare. There most likely will not be any significant negative impact from these changes since 1) the number of procedures covered by Medicare has increased, and 2) reimbursement for certain complex procedures has increased, thus more than offsetting decreases for other types of procedures.

In fact, CMS has recognized that ACSs provide surgical services at costs lower than hospitals mainly because they typically limit their procedures to those that are simpler, lower-risk and ambulatory. In a controversial leap forward, starting in 2015, CMS approved several new spine surgery codes for procedures neurosurgeons can perform at an ASC. These include cervical spine fusion, lumbar spine fusion, spine fusion-extra segment, cervical spine disc surgery, laminectomy-single lumbar, removal of spinal lamina and decompression-spinal cord.

Surgical procedures can be performed in a freestanding ASC more cost-effectively than in the inpatient setting for a number of reasons, including lower facility development costs, more efficient staffing and space utilization, and a specialized operating philosophy that is focused on cost containment. Interest in ASCs has grown as managed care organizations have sought a more cost-effective alternative to traditional inpatient services.

Richard N.W. Wohns, MD, JD, MBA, a neurosurgeon, is the founder and president of NeoSpine, in Seattle.
Disclosure: Wohns reports no relevant financial disclosures.

Lower complication rates

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 whether we have data that support allowing patients to go home the same day as their operation. The answer is that 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 country, 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 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. Currently, cervical arthroplasty and posterior laminoforaminotomy are also routinely completed on an outpatient basis. 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.

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 the types of spine procedures performed on an outpatient basis will increase.

Rick C. Sasso, MD, is the chief of spine surgery at Indiana University School of Medicine and practices at Indiana Spine Group, in Indianapolis.
Disclosure: Sasso reports no relevant financial disclosures.

• Reference:
• Best NM, et al. J Spinal Disord Tech. 2006;doi:10.1097/01.bsd.0000210119.47387.44.
• Best NM, et al. J Spinal Disord Tech. 2007;doi:10.1097/01.brs.0000261486.51019.4a.
• Garringer SM, et al. J Spinal Disord Tech. 2010;doi:10.1097/BSD.0b013e3181bd0419.
• Lee MJ, et al. Evid Based Spine Care J. 2014;doi:10.1055/s-0034-1389088.
• Miller JW, et al. SAS J. 2011;doi:10.1016/j.esas.2010.11.002.