Management by outcomes: efficiency and operational success in the ambulatory surgery center

Current Concepts in the Business of Orthopaedics

Practice management within orthopaedic surgery demands a multifaceted skillset including clinical expertise, technical proficiency, and business acumen, yet the latter is rarely taught during orthopaedic training. As the healthcare system evolves in the United States, surgeons continue to face challenges such as decreasing reimbursements, increased regulatory burdens, and potential for practice acquisition. To remain competitive and provide exceptional care for patients, orthopaedic surgeons must cultivate a business-minded approach. This article highlights the growing significance of the business of orthopaedics and offers guidance on ambulatory surgical center ownership models, effective management of ancillary services, the effect of private equity in orthopaedic practice, real estate investment opportunities in medical office buildings, and the importance of brand recognition. By understanding these concepts, orthopaedic surgeons can exercise greater control over their practice's finances while providing quality care for their patients.

Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures

BACKGROUND

Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities.

METHODS

The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications.

RESULTS

A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events.

CONCLUSIONS

This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Why can't we improve turnover time? A systematic review

BACKGROUND

Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention.

MATERIAL AND METHODS

A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline.

RESULTS

A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%).

DISCUSSION

There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

Comprehensive review of a large cohort of outpatient versus inpatient open renal and bladder surgery in children

INTRODUCTION

Outpatient surgery and pediatric ambulatory surgery centers continue to have increasing popularity among pediatric urologist for minor surgeries. Past studies have shown that open renal and bladder surgeries (i.e. nephrectomy, pyeloplasty and ureteral reimplantation) can also be done in an outpatient setting. With health care costs continuing to rise, it may be reasonable to explore performing these surgeries as an outpatient and consider performing them in a pediatric ambulatory surgery center.

OBJECTIVE

Our study assesses the safety and utility of outpatient open renal and bladder surgeries in children compared to those done as inpatients.

STUDY DESIGN

IRB-approved chart review was performed on patients undergoing nephrectomy, ureteral reimplantation, complex ureteral reimplantation, and pyeloplasty by a single pediatric urologist between January 2003-March 2020. Procedures were performed at a freestanding pediatric surgery center (PSC) and a children's hospital (CH). Demographics, type of procedures, American Society of Anesthesiologists score, operative times, time to discharge, ancillary procedures, readmission or ER visits within 72 h were reviewed. Home zip codes were used to determine the distance from pediatric surgery center and children's hospital.

RESULTS

980 procedures were evaluated. Of these, 94% procedures were performed as an outpatient and 6% procedures were performed as inpatients. 40% of patients underwent ancillary procedures. Outpatients had a significantly lower age, ASA score, operative time, and readmission or return to ER within 72 h (1.5% vs. 6.2%). Twelve patients were readmitted (9 outpatient, 3 inpatient) and six returned to the ER (5 outpatient, 1 inpatient). 15/18 of these patients underwent reimplantations. Four required early reoperation on postoperative day (POD)2-3. Only one outpatient reimplant was admitted one day later. PSC patients lived farther away.

DISCUSSION

Outpatient open renal and bladder surgery was found to be safely performed in our patients. In addition, it did not matter whether the operation was done in the children's hospital or pediatric ambulatory surgery center. Since outpatient surgery has been shown to be significantly less expensive than inpatient surgery, it is reasonable for pediatric urologist to consider performing these operations in the outpatient setting.

CONCLUSIONS

Our experience shows that an outpatient approach to open renal and bladder procedures is safe and should be considered when counseling families about treatment options.

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BACKGROUND

The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs.

AIM

To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries.

METHODS

A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared.

MAIN OUTCOME MEASURE

The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups.

RESULTS

A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial.

CLINICAL IMPLICATIONS

IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer.

STRENGTHS & LIMITATIONS

The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding.

CONCLUSION

ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review

INTRODUCTION

Erectile dysfunction is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The preponderance of available data on IPP surgery derives from institutional studies, most notably from academic centers or large single-surgeon series, where the majority of procedures are performed in a hospital setting. Because insurance companies and health systems look to reduce health care costs, IPP surgery in outpatient freestanding ambulatory surgery centers (ASC) is becoming more prevalent.

AIM

To review the utility of surgery in an ASC setting and to explore its role in the modern practice of urology, focusing on IPP implantation.

METHODS

A critical review was performed of the literature on ambulatory surgery, with specific focus on IPP surgery, using the PubMed database. Key search terms and phrases included erectile dysfunction, penile prosthesis, ambulatory surgery, ambulatory surgery center, outpatient surgery.

MAIN OUTCOME MEASURE

The main outcome measure was the use of IPP implantation in an ASC.

RESULTS

In contemporary surgical practice, the implementation of ambulatory surgery in free-standing centers is increasing. The principal benefits include reducing cost and improving efficiency. Studies on the modern use of IPPs support the prospect of implantation in an ambulatory setting, which can achieve similar outcomes to surgeries classically performed in the inpatient hospital setting. Novel approaches to anesthesia, surgical, and nursing care have revolutionized IPP surgery so that it can now be safely and effectively performed in the ambulatory setting.

CONCLUSION

The role of ambulatory IPP implantation has increased, with the majority of cases being performed outside the hospital. Although there will always be a need for hospital-based surgery, such as significant medical comorbidities, more studies demonstrating the safety and feasibility of ambulatory surgery are needed. For those men who would otherwise be candidates for ambulatory surgery but whose insurance mandates hospital-based treatment, such studies proving utility, safety, and reduced cost could inspire policy change and broaden the ambulatory practice of IPP surgery. Segal RL, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review. Sex Med Rev 2020;8:338-347.

Beyond orthogeriatric co-management model: benefits of implementing a process management system for hip fracture

Hip fracture is a major health care problem worldwide. Business process management systems (PMSs) have made significant contributions in health care environments to improve patient care standards. The effectiveness of PMS applied to hip fracture in older adults in the acute phase has been demonstrated.

INTRODUCTION

Fragility fracture is a major health care problem worldwide. Business PMSs have made significant contributions in health care environments to improve patient care standards. It is a new way of management that defines a homogeneous application procedure involving eliminating steps that add no value and developing explicit supervision criteria, in addition to identifying the appropriate managers.

PURPOSE

The aim of our trial was to assess the effectiveness of the PMS applied to hip fracture versus the orthogeriatric co-management model in the acute phase.

METHODS

All consecutive patients aged ≥ 65 who were admitted to Hospital Universitario Infanta Leonor between January 1, 2009, and December 31, 2016, for acute hip fracture surgery were included. We compared the effectiveness indicators in the acute phase between the preprocess period (orthogeriatric co-management) and the process period.

RESULTS

One thousand two hundred twenty-two patients were included (76.6% women). Mean age (SD) was 83.9 (6.4) years. Effectiveness management indicators are the following: length of hospital stay, time to admission to the ward from the emergency department, preoperative stay, surgery in < 48 h, and the operating room availability which were all improved in the process period with statistical significance. Effectiveness clinical indicators are the following: the numbers of patients with operated limb loading approved after surgery, discharged to home, and with osteoporosis treatment postfracture at the time of discharge which were statistically significantly higher in the process period, and the number of patients who suffered from delirium was statistically significantly lower in the process period. The number of in-hospital deaths was lower during the process period without statistical significance.

CONCLUSION

Our results demonstrated the effectiveness of the PMS applied to hip fracture in older adults compared with an orthogeriatric co-management model in the acute phase, based on both management indicators and clinical indicators.

Surgical Treatment of Supracondylar Humeral Fractures in a Freestanding Ambulatory Surgery Center is as Safe as and Faster and More Cost-Effective Than in a Children's Hospital

BACKGROUND

Despite an 88% increase in the number of pediatric fractures treated in ambulatory surgery centers (ASCs) over a 10-year period, few studies have compared outcomes of fracture treatment performed in a freestanding ASC compared with those performed in the hospital (HOSP) or hospital outpatient department (HOPD). The purpose of this study was to compare clinical and radiographic outcomes, treatment times, and costs for treatment of Gartland type II supracondylar humeral (SCH) fracture in the ASC, HOSP, and HOPD.

METHODS

Retrospective review identified pediatric patients with isolated Gartland type II SCH fractures who had closed reduction and percutaneous pinning (CRPP) by board-certified orthopaedic surgeons from January 2012 to September 2016. On the basis of the location of their treatment, patients were divided into 3 groups: HOSP, HOPD, and ASC. All fractures were treated with CRPP under fluoroscopic guidance using 2 parallel or divergent smooth Kirschner wires. Radiographs obtained before and after CRPP and at final follow-up noted the anterior humeral line index (HLI) and Baumann angle. Statistical analysis compared all 3 groups for outcomes, complications, treatment time/efficiency, and charges.

RESULTS

Record review identified 231 treated in HOSP, 35 in HOPD, and 50 in ASC. Radiographic outcomes in terms of Baumann angle and HLI did not differ significantly between the groups at any time point except preoperatively when the HLI for the HOSP patients was lower (P=0.02), indicating slightly greater displacement than the other groups. Overall complication rates were not significantly different among the groups, nor were occurrences of individual complications. The mean surgical time was significantly shorter (P<0.0001) in ASC patients than in HOPD and HOSP patients, and total charges were significantly lower (P<0.001).

CONCLUSIONS

Gartland type II SCH fractures can be safely treated in a freestanding ASC with excellent clinical and radiographic outcomes equal to those obtained in the HOSP and HOPD; treatment in the ASC also is more efficient and cost-effective.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Surgical Efficiency of Anterior Cruciate Ligament Reconstruction in Outpatient Surgical Center Versus Hospital Operating Room

Anterior cruciate ligament (ACL) reconstructions are complex orthopedic procedures in which a proficient team is of vital importance. Outpatient surgical centers (OSCs) often provide orthopedic-specific teams; however, hospital operating rooms (ORs) commonly rotate staff. The purpose of this study was to compare the efficiency of pediatric ACL reconstructions between a surgical center and a hospital OR owned and directed by a single institution. Cases examined involved pediatric patients, aged 12 to 18 years (mean age, 15.9±1.5 years), who underwent ACL reconstructions by a single orthopedic surgeon from 2009 to 2014. Procedural efficiency was defined as shorter total OR time, less total staff, and fewer support staff changes. Total OR time was also broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. A total of 49 ACL reconstructions were performed in healthy athletes, with 28 surgeries at the OSC (mean age, 15.7±1.3 years) and 21 surgeries in the hospital OR (mean age, 16.1±1.8 years). Overall efficiency was higher at the OSC, with total OR time improved by 30 minutes on average (P=.0001) with less total staff (P=.0002). Surgical technician and nursing changes occurred 6 and 2.5 times more often in the hospital OR, respectively. Procedural efficiency was greater at the OSC. The provision of consistent and experienced orthopedicspecific teams allows for improvement in OR efficiency, cost, and value. [Orthopedics. 2017; 40(5):297-302.].

Do Surgical Times and Efficiency Differ Between Inpatient and Ambulatory Surgery Centers That are Both Hospital Owned?

PURPOSE

The aim of this study was to examine the differences in primary anterior cruciate ligament reconstruction (ACLR) surgical time and operation room (OR) work efficiency between inpatient and ambulatory facilities within the same institution.

METHODS

Patients studied included those who underwent primary ACLR at either the inpatient hospital or the ambulatory facility by a single orthopaedic surgeon on elective surgery days. Time variables were calculated for ACLR to compare the 2 facilities. The OR work efficiency was calculated as the percentage of work that was completed before mid-day that was determined by the midpoint of the surgical day at each facility.

RESULTS

Two hundred twenty-seven ACLR surgeries were performed on 187 elective surgery days, 153 surgeries at the inpatient facility and 74 at the outpatient facility. The mean age at the time of surgery was 14.9±2.2 years. The ACLR surgeries at the ambulatory facility were of shorter duration than those at the inpatient facility (P<0.0001). One OR was most commonly utilized and 2 to 3 surgeries were performed on most surgery days at both facilities. Seven nurses served as alternating circulators at the ambulatory facility compared with 41 nurses serving in the same capacity at the inpatient facility. The median turnover time was longer at the inpatient facility compared with the ambulatory facility. OR work efficiency (work done before mid-day) was 72.5% at the ambulatory facility and 49.5% at the inpatient facility, P<0.0001. If 2 ACLR surgeries were performed consecutively, the surgery day lasted for 6 hours at the hospital-owned ambulatory surgery center compared with 9 hours at the inpatient hospital.

CONCLUSIONS

Despite the common variables of the same surgeon performing the same surgery at facilities owned by the same institution primarily working in a single OR, differences exist in OR procedure time and work efficiency.

LEVEL OF EVIDENCE

Level III.

Ambulatory surgery centers and outpatient urologic surgery among Medicare beneficiaries

OBJECTIVE

To determine the effect of an ambulatory surgery center (ASC) opening in a healthcare market on utilization and quality of outpatient urologic surgery.

METHODS

This is a retrospective cohort study of Medicare beneficiaries undergoing outpatient urologic surgery from 2001 to 2010. Markets were classified into 3 groups based on ASC status (ie, those with ASCs, those without ASCs, and those where ASCs were introduced). Multiple propensity score methods adjusted for differences between markets and general linear mixed models determined the effect of ASC opening on utilization and quality, defined by mortality and hospital admission within 30 days of the index procedure.

RESULTS

During the study period, 195 ASCs opened in markets previously without one. Rates of hospital-based urologic surgery in markets where ASCs were introduced declined from 221 to 214 procedures per 10,000 beneficiaries in the 4 years after baseline. In contrast, rates in the other 2 market types increased over the same period (P<.001). Rates of outpatient urologic surgery overall (ie, in the hospital and ASC) demonstrated similar growth across market types during same period (P=.56). The introduction of an ASC into a market was not associated with increases in hospital admission or mortality (P>.5).

CONCLUSION

The introduction of an ASC into a healthcare market lowered rates of outpatient urologic surgery performed in the more expensive hospital setting. This redistribution was not associated with declines in quality or with greater growth in overall outpatient surgery use.

Understanding the diffusion of ambulatory surgery centers

BACKGROUND

Outpatient surgery is increasingly delivered at freestanding ambulatory surgery centers (ASCs), which are thought to deliver quality care at lower costs per episode. The objective of this study was to understand potential facilitators and/or barriers to the introduction of freestanding ASCs in the United States.

METHODS

This is an observational study conducted from 2008 to 2010 using a 20% sample of Medicare claims. Potential determinants of ASC dissemination, including population, system, and legal factors, were compared between markets that always had ASCs, never had ASCs, and those that had new ASCs open during the study. Multivariable logistic regression was used to determine characteristics of markets associated with the opening of a new facility in a previously naïve market.

RESULTS

New ASCs opened in 67 previously naïve markets between 2008 and 2010. ASCs were more likely to open in hospital service areas that were urban (adjusted odds ratio [OR], 4.10; 95% confidence interval [CI], 1.51-10.96), had higher per capita income (adjusted OR, 3.83; 95% CI, 1.43-10.45), and had less competition for outpatient surgery (adjusted OR, 2.13; 95% CI, 1.02-4.45). Legal considerations and latent need, as measured by case volumes of hospital-based outpatient surgery in 2007, were not associated with the opening of a new ASC.

CONCLUSIONS

Freestanding ASCs opened in advantageous socioeconomic environments with the least amount of competition. Because of their associated efficiency advantages, policy makers might consider strategies to promote ASC diffusion in disadvantaged markets to potentially improve access and reduce costs.

Using improvement science methods to increase accuracy of surgical consents

The surgical consent serves as a key link in preventing breakdowns in communication that could lead to wrong-patient, wrong-site, or wrong-procedure events. We conducted a quality improvement initiative at a large, urban pediatric academic medical center to reliably increase the percentage of informed consents for surgical and medical procedures with accurate safety data information at the first point of perioperative contact. Improvement activities focused on awareness, education, standardization, real-time feedback and failure identification, and transparency. A total of 54,082 consent forms from 13 surgical divisions were reviewed between May 18, 2011, and November 30, 2012. Between May 2011 and June 2012, the percentage of consents without safety errors increased from a median of 95.4% to 99.7%. Since July 2012, the median has decreased slightly but has remained stable at 99.4%. Our results suggest that effective safety checks allow discovery and prevention of errors.

Performance of open renal and bladder surgery at a freestanding pediatric surgery center

PURPOSE

More ambulatory urological surgeries are being performed in children due to innovations in techniques and trends in medical care. Pediatric ambulatory surgery centers are seeing more complex procedures that were traditionally hospital based.

MATERIALS AND METHODS

A total of 343 open renal and bladder procedures were performed by a single pediatric urologist at a freestanding pediatric surgery center (12 miles from a pediatric hospital) between July 2003 and October 2009. Charts were analyzed to determine the demographics and complications necessitating hospitalization within 48 hours of discharge home.

RESULTS

During the study period 28 children (mean age 1.62 years, range 4 months to 6 years) underwent nephrectomy, 50 (2.92 years, 3 months to 12 years) underwent pyeloplasty, 216 (4.01 years, 8 months to 21 years) underwent simple ureteral reimplantation and 49 underwent complex ureteral reimplantation (2.79 years, 5 months to 12 years). Two children were acutely transferred to the hospital, 1 for pain management and 1 for respiratory distress. Two additional children were hospitalized within 48 hours, 1 due to partial ureteral obstruction, and 1 due to dehydration and urinary tract infection. All 4 of these patients underwent simple reimplantation surgery.

CONCLUSIONS

Carefully selected children undergoing open renal and bladder procedures can be expected to be discharged home on the same day. Older children, those with significant comorbidities and those undergoing procedures later in the day may not be ideal outpatient candidates. Nephrectomy, pyeloplasty and ureteral reimplantation are excellent outpatient procedures for most children.