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Im J, Soliman MAR, Quiceno E, Elbayomy AM, Aguirre AO, Kuo CC, Sood EM, Khan A, Levy HW, Ghannam MM, Pollina J, Mullin JP. Comparative analysis of patient demographics, perioperative outcomes, and adverse events after lumbar spinal fusion between urban and rural hospitals: an analysis of the National Inpatient Sample (NIS) database. Clin Neurol Neurosurg 2024; 243:108375. [PMID: 38901378 DOI: 10.1016/j.clineuro.2024.108375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Rural location of a patient's primary residence has been associated with worse clinical and surgical outcomes due to limited resource availability in these parts of the US. However, there is a paucity of literature investigating the effect that a rural hospital location may have on these outcomes specific to lumbar spine fusions. METHODS Using the National Inpatient Sample (NIS) database, we identified all patients who underwent primary lumbar spinal fusion in the years between 2009 and 2020. Patients were separated according to whether the operative hospital was considered rural or urban. Univariable and multivariable regression models were used for data analysis. RESULTS Of 2,863,816 patients identified, 120,298 (4.2 %) had their operation at a rural hospital, with the remaining in an urban hospital. Patients in the urban cohort were younger (P < .001), more likely to have private insurance (39.81 % vs 31.95 %, P < .001), and fewer of them were in the first (22.52 % vs 43.00 %, P < .001) and second (25.96 % vs 38.90 %, P < .001) quartiles of median household income compared to the rural cohort. The urban cohort had significantly increased rates of respiratory (4.49 % vs 3.37 %), urinary (5.25 % vs 4.15 %), infectious (0.49 % vs 0.32 %), venous thrombotic (0.57 % vs 0.24 %, P < .001), and neurological (0.79 % vs 0.36 %) (all P < .001) perioperative complications. On multivariable analysis, the urban cohort had significantly increased odds of the same perioperative complications: respiratory (odds ratio[OR] = 1.48; 95 % confidence interval [CI], 1.26-1.74), urinary (OR = 1.34; 95 %CI, 1.20-1.50), infection (OR = 1.63; 95 %CI, 1.23-2.17), venous thrombotic (OR = 1.79; 95 %CI, 1.32-2.41), neurological injury (OR = 1.92; 95 %CI, 1.46-2.53), and localized infection (OR = 1.65; 95 %CI, 1.25-2.17) (all P < .001). CONCLUSIONS Patients undergoing lumbar fusions experience significantly different outcomes based on the rural or urban location of the operative hospital.
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Affiliation(s)
- Justin Im
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA; Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ahmed M Elbayomy
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Evan M Sood
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Hannon W Levy
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, NY, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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Arnautovic A, Mijares J, Begagić E, Ahmetspahić A, Pojskić M. Four-level ACDF surgical series 2000-2022: a systematic review of clinical and radiological outcomes and complications. Br J Neurosurg 2024:1-12. [PMID: 38606493 DOI: 10.1080/02688697.2024.2337020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE The primary objective of this investigation is to systematically scrutinize extant surgical studies delineating Four-Level Anterior Cervical Discectomy and Fusion (4L ACDF), with a specific emphasis on elucidating reported surgical indications, clinical and radiological outcomes, fusion rates, lordosis correction, and the spectrum of complication rates. METHODS The literature review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, employing the MEDLINE (PubMed), Embase, and Scopus databases. This analysis encompasses studies implementing the 4L ACDF procedure, with detailed extraction of pertinent data pertaining to surgical methodologies, types of employed interbody cages, clinical and radiological endpoints, rates of fusion, and the incidence of complications. RESULTS Among the 15 studies satisfying inclusion criteria, a marginal increment in the year 2022 (21.4%) was discerned, with a preponderance of study representation emanating from China (35.7%) and the United States (28.6%). 50% of the studies were single-surgeon studies. Concerning follow-up, studies exhibited variability, with 42.9% concentrating on periods of five years or less, and an equivalent proportion extending beyond this timeframe. Across the amalgamated cohort of 2457 patients, males constituted 51.6%, manifesting a mean age range of 52.2-61.3 years. Indications for surgery included radiculopathy (26.9%) and myelopathy (46.9%), with a predilection for involvement at C3-7 (24.9%). Meta-analysis yielded an overall complication rate of 16.258% (CI 95%: 14.823%-17.772%). Dysphagia (4.563%), haematoma (1.525%), hoarseness (0.205%), C5 palsy (0.176%) were the most prevalent complications of 4L ACDF. Fusion rates ranging from 41.3% to 94% were documented. CONCLUSION The 4L ACDF is commonly performed to address mylopathy and radiculopathy. While the surgery carries a complication rate of around 16%, its effectiveness in achieving bone fusion can vary considerably.
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Affiliation(s)
- Alisa Arnautovic
- George Washington University School of Medicine, Washington, DC, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Joseph Mijares
- George Washington University School of Medicine, Washington, DC, USA
| | - Emir Begagić
- Department of General Medicine, School of Medicine, University of Zenica, Zenica, Bosnia and Herzegovina
| | - Adi Ahmetspahić
- Department of Neurosurgery, Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina
| | - Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- School of Medicine, Josip Juraj Strossmayr University, Osijek, Croatia
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Schönnagel L, Tani S, Vu-Han TL, Zhu J, Camino-Willhuber G, Dodo Y, Caffard T, Chiapparelli E, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Hughes AP, Sama AA. Predicting conversion of ambulatory ACDF patients to inpatient: a machine learning approach. Spine J 2024; 24:563-571. [PMID: 37980960 DOI: 10.1016/j.spinee.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/29/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND CONTEXT Machine learning is a powerful tool that has become increasingly important in the orthopedic field. Recently, several studies have reported that predictive models could provide new insights into patient risk factors and outcomes. Anterior cervical discectomy and fusion (ACDF) is a common operation that is performed as an outpatient procedure. However, some patients are required to convert to inpatient status and prolonged hospitalization due to their condition. Appropriate patient selection and identification of risk factors for conversion could provide benefits to patients and the use of medical resources. PURPOSE This study aimed to develop a machine-learning algorithm to identify risk factors associated with unplanned conversion from outpatient to inpatient status for ACDF patients. STUDY DESIGN/SETTING This is a machine-learning-based analysis using retrospectively collected data. PATIENT SAMPLE Patients who underwent one- or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021. OUTCOME MEASURES Length of stay, conversion rates from ambulatory setting to inpatient. METHODS Patients were divided into two groups based on length of stay: (1) Ambulatory (discharge within 24 hours) or Extended Stay (greater than 24 hours but fewer than 48 hours), and (2) Inpatient (greater than 48 hours). Factors included in the model were based on literature review and clinical expertise. Patient demographics, comorbidities, and intraoperative factors, such as surgery duration and time, were included. We compared the performance of different machine learning algorithms: Logistic Regression, Random Forest (RF), Support Vector Machine (SVM), and Extreme Gradient Boosting (XGBoost). We split the patient data into a training and validation dataset using a 70/30 split. The different models were trained in the training dataset using cross-validation. The performance was then tested in the unseen validation set. This step is important to detect overfitting. The performance was evaluated using the area under the curve (AUC) of the receiver operating characteristics analysis (ROC) as the primary outcome. An AUC of 0.7 was considered fair, 0.8 good, and 0.9 excellent, according to established cut-offs. RESULTS A total of 581 patients (59% female) were available for analysis. Of those, 140 (24.1%) were converted to inpatient status. The median age was 51 (IQR 44-59), and the median BMI was 28 kg/m2 (IQR 24-32). The XGBoost model showed the best performance with an AUC of 0.79. The most important features were the length of the operation, followed by sex (based on biological attributes), age, and operation start time. The logistic regression model and the SVM showed worse results, with an AUC of 0.71 each. CONCLUSIONS This study demonstrated a novel approach to predicting conversion to inpatient status in eligible patients for ambulatory surgery. The XGBoost model showed good predictive capabilities, superior to the older machine learning approaches. This model also revealed the importance of surgical duration time, BMI, and age as risk factors for patient conversion. A developing field of study is using machine learning in clinical decision-making. Our findings contribute to this field by demonstrating the feasibility and accuracy of such methods in predicting outcomes and identifying risk factors, although external and multi-center validation studies are needed.
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Affiliation(s)
- Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, 541 E. 71st Street, New York, NY 10021, USA
| | - Gaston Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - William D Zelenty
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Federico VP, Nie JW, Hartman TJ, Oyetayo OO, Zheng E, MacGregor KR, Massel DH, Sayari AJ, Singh K. The Surgical Learning Curve for Cervical Disk Replacement. Clin Spine Surg 2024; 37:E82-E88. [PMID: 37684720 DOI: 10.1097/bsd.0000000000001530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/10/2023] [Indexed: 09/10/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To characterize an experienced single surgeon learning curve for cervical disk replacement (CDR). SUMMARY OF BACKGROUND DATA A single surgeon learning curve has not been established for CDR. METHODS Patients undergoing CDR were included. The cumulative sum of operative time was utilized to separate cases into 3 phases: learning, practicing, and mastery. Demographics, perioperative characteristics, complications, patient-reported outcomes (PROs), and radiographic outcomes were collected preoperatively and up to 1 year postoperatively. PROs included Patient-reported Outcomes Measurement Information System Physical Function, 12-item Short Form-12 Physical Component Score, 12-item Short Form-12 Mental Component Score, visual analog scale (VAS) arm, VAS neck, Neck Disability Index. Radiographic outcomes included segmental angle/segmental range of motion/C2-C7 range of motion. Minimum clinically important difference achievement was determined through a comparison of previously established values. RESULTS A total of 173 patients were identified, with 14 patients in the learning phase, 42 patients in the practicing phase, and 117 patients in the mastery phase. Mean operative time and mean postoperative day 0 narcotic consumption were significantly higher in the learning phase. The preoperative segmental angle was significantly lower for the learning phase, though these differences were eliminated at the final postoperative time point. Patients in the learning phase reported worse improvement to 6-week postoperative, final postoperative, and worse overall final postoperative VAS Arm scores compared with practicing and mastery phases. CONCLUSIONS For an experienced spine surgeon, the learning phase for CDR was estimated to span 14 patients. During this phase, patients demonstrated longer operative times, higher postoperative narcotic consumption, and worse postoperative VAS Arm scores. Radiographically, no postoperative differences were noted between different phases of mastery. This single surgeon learning curve demonstrates that CDR may be performed safely and with comparable outcomes by experienced spine surgeons despite decreased operative efficiency in the learning phase.
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Affiliation(s)
- Vincent P Federico
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Tani S, Okano I, Dodo Y, Camino-Willhuber G, Caffard T, Schönnagel L, Chiapparelli E, Amoroso K, Tripathi V, Arzani A, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sokunbi G, Sama AA. Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients. Spine (Phila Pa 1976) 2023; 48:1427-1435. [PMID: 37389987 DOI: 10.1097/brs.0000000000004767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
STUDY DESIGN/SETTING A retrospective observational study. OBJECTIVE The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient. SUMMARY OF BACKGROUND DATA Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion. MATERIALS AND METHODS Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h). RESULTS In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management. CONCLUSIONS Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.
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Affiliation(s)
- Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | | | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, NY
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Monk SH, Hani U, Pfortmiller D, Adamson TE, Bohl MA, Branch BC, Kim PK, Smith MD, Holland CM, McGirt MJ. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis. Neurosurgery 2023; 93:867-874. [PMID: 37067954 DOI: 10.1227/neu.0000000000002483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/09/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series. OBJECTIVE To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting. METHODS A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed. RESULTS There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery. CONCLUSION In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Ummey Hani
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Michael A Bohl
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
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Ye J, Zielinski E, Richardson S, Petrone B, McCarthy MM, Boody B. Is It Safe to Perform True Outpatient Multilevel ACDFs in a Surgery Center? Clin Spine Surg 2023; 36:151-153. [PMID: 36727974 DOI: 10.1097/bsd.0000000000001415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Jason Ye
- Indiana Spine Group, Carmel Carmel
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Epstein NE. Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s)? Surg Neurol Int 2023; 14:110. [PMID: 37151427 PMCID: PMC10159315 DOI: 10.25259/sni_175_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background:
Can anterior cervical diskectomy/fusion (ACDF) be safely performed in ambulatory surgical centers (ASC’s: i.e. discharges 4-7.5 hr. postoperatively) that meet the following stringent “exclusion criteria”; elevated Body Mass Index (BMI), major comorbidities, age > 65, American Society of Anesthesiology (ASA) scores > II, and largely multilevel ACDF.
Materials:
Presently, most ACDF are still being performed in hospital-based outpatient surgical centers (HBSC: utilizing 23-hour stays), or as inpatients.
Results:
Notably, unreliable disparate study designs involving very different patient populations resulted in nearly comparable, but implausible outcomes for 1-level vs. multilevel ACDF series performed in ASC. A summary of these outcome data included the following rates of; i.e. postoperative hospital transfers (0-6%), 30-day (up to 2.2%), and up to 90 day (2.2%) emergency department (ED) visits, readmissions, and reoperations.
Conclusion:
Nevertheless, it is just common sense that “less should be less”, that 1-level ACDF should involve less risk compared with multilevel ACDF procedures performed in ASC.
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Monk SH, Rossi VJ, Atkins TG, Karimian B, Pfortmiller D, Kim PK, Adamson TE, Smith MD, McGirt MJ, Holland CM, Deshmukh VR, Branch BC. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol. World Neurosurg 2023; 171:e471-e477. [PMID: 36526224 DOI: 10.1016/j.wneu.2022.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Vincent J Rossi
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tyler G Atkins
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Brandon Karimian
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Vinay R Deshmukh
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
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10
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Monk SH, Zeitouni D, Cowan D, Rossi VJ, Parish JM, Dyer EH, Smith MD, Kim PK, Adamson TE. Feasibility and Safety of Microendoscopic Posterior Cervical Foraminotomy in an Ambulatory Surgery Center: A Longitudinal Experience with 1000 Cases. World Neurosurg 2023; 173:e228-e233. [PMID: 36787856 DOI: 10.1016/j.wneu.2023.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE Ambulatory surgery centers (ASCs) have become an increasingly attractive setting for spine surgery in recent decades. Although posterior cervical foraminotomy (PCF) is widely performed in ASCs, there are no studies supporting the safety of this practice. We aimed to demonstrate the feasibility and safety of microendoscopic (MED)-PCF in a large cohort of patients at a freestanding ASC. METHODS Consecutive patients undergoing MED-PCF for unilateral cervical radiculopathy at a single freestanding ASC from January 2013 to December 2020 were queried. Standard demographic and perioperative data were collected. Outcomes included need for inpatient transfer, perioperative complications, 30-day readmission, 30-day reoperation, and clinical improvement according to the Odom criteria. RESULTS A total of 1106 patients underwent MED-PCF during the study period. Mean age was 53.3 ± 10.3 years. Most patients underwent decompression at C5-6 (31.4%) or C6-7 (51.9%). Approximately 10% underwent surgery at multiple levels. Mean operative time was 40.0 ± 16.4 minutes. There were no intraoperative or immediate postoperative complications. All patients were discharged home within a few hours of surgery. The rates of 30-day readmission (0.81%) and reoperation (0.36%) were exceedingly low. Nearly 3 quarters of patients (73.7%) achieved a good or excellent clinical outcome (73.7%) according to the Odom criteria. CONCLUSIONS MED-PCF can be performed in a freestanding ASC with exceedingly low rates of perioperative complications and short-term readmission or reoperation. Our findings support the ongoing migration of PCF from the hospital to the ambulatory setting. Future studies assessing patient-reported outcomes and long-term reoperation rates are necessary.
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Affiliation(s)
- Steve H Monk
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA.
| | - Daniel Zeitouni
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - David Cowan
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Vincent J Rossi
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Jonathan M Parish
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - E Hunter Dyer
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Mark D Smith
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Paul K Kim
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
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11
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Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis. Spine (Phila Pa 1976) 2023; 48:155-163. [PMID: 36607626 DOI: 10.1097/brs.0000000000004500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. SUMMARY OF BACKGROUND DATA Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. MATERIALS AND METHODS A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. CONCLUSION Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.
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12
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Is Thoracic Paddle Lead Spinal Cord Stimulator Implantation Safe in an Ambulatory Surgery Center? World Neurosurg 2023; 170:e436-e440. [PMID: 36379362 DOI: 10.1016/j.wneu.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Spinal cord stimulation is an effective treatment modality for chronic pain. Although percutaneous leads are commonly placed in the outpatient setting, paddle leads are typically implanted in the inpatient setting. Given the substantial cost savings associated with the ambulatory setting, we aimed to demonstrate the feasibility and safety of thoracic paddle lead implantation in a freestanding ambulatory surgery center (ASC). METHODS Consecutive patients undergoing thoracic paddle lead implantation at a single freestanding ASC from January 2015 to December 2020 were queried. Demographic, perioperative, and outcome data were collected. Primary outcomes were incidence of intraoperative or immediate postoperative complications and need for inpatient transfer. Secondary outcomes included readmission at 30 and 90 days and reoperation at 30 days, 90 days, and 1 year. RESULTS A total of 46 patients underwent ambulatory thoracic paddle lead implantation over the study period. Two patients (4.3%) suffered an immediate postoperative complication requiring return to surgery at the ASC-one for an epidural hematoma, and one for a flank hematoma. All but one patient (97.8%) were discharged home on the day of surgery. The overall 30- and 90-day readmission rates were 4.3% and 6.5%, respectively. One patient (2.2%) required reoperation for a mechanical complication. No device-related infections were noted during the follow-up period. CONCLUSIONS Thoracic laminotomy for paddle lead spinal cord stimulator implantation can be performed in a freestanding ASC with complication rates comparable to the hospital setting. Future comparative studies that assess clinical outcomes and cost are necessary to determine the cost-effectiveness of the ambulatory setting.
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13
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Mooney J, Michalopoulos GD, Zeitouni D, Sammak SE, Alvi MA, Wang MY, Coric D, Chan AK, Mummaneni PV, Bisson EF, Sherrod B, Haid RW, Knightly JJ, Devin CJ, Pennicooke BH, Asher AL, Bydon M. Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes. J Neurosurg Spine 2022; 37:485-497. [PMID: 35523251 DOI: 10.3171/2022.3.spine211558] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery. METHODS The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval. RESULTS A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery. CONCLUSIONS Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.
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Affiliation(s)
- James Mooney
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Giorgos D Michalopoulos
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel Zeitouni
- 4School of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Sally El Sammak
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael Y Wang
- 5Department of Neurological Surgery, University of Miami, Florida
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Andrew K Chan
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Erica F Bisson
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Brandon Sherrod
- 8Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | | | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Clinton J Devin
- 11Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado; and
| | - Brenton H Pennicooke
- 12Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Mohamad Bydon
- 2Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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14
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Chatterjee A, Rbil N, Yancey M, Geiselmann MT, Pesante B, Khormaee S. Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 11:100132. [PMID: 35783006 PMCID: PMC9243295 DOI: 10.1016/j.xnsj.2022.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Nada Rbil
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Michael Yancey
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Matthew T. Geiselmann
- New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Benjamin Pesante
- The University of Connecticut School of Medicine, Farmington, CT, United States
| | - Sariah Khormaee
- Weill Cornell Medical College, New York, NY, United States
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
- Corresponding author: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
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15
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Chapman EK, Doctor T, Gal JS, Shuman WH, Neifert SN, Martini ML, McNeill IT, Rothrock RJ, Schupper AJ, Caridi JM. The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis. Spine (Phila Pa 1976) 2021; 46:1535-1541. [PMID: 34027927 DOI: 10.1097/brs.0000000000004127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesia, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion. J Am Acad Orthop Surg 2021; 29:758-766. [PMID: 33428349 DOI: 10.5435/jaaos-d-20-00894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/07/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The movement toward reducing healthcare expenditures has led to an increased volume of outpatient anterior cervical diskectomy and fusions (ACDFs). Appropriateness for outpatient surgery can be gauged based on the duration of recovery each patient will likely need. METHODS Patients undergoing 1- or 2-level ACDFs were retrospectively identified at a single Level I spine surgery referral institution. Length of stay (LOS) was categorized binarily as either less than two midnights or two or more midnights. The data were split into training (80%) and test (20%) sets. Two multivariate regressions and three machine learning models were developed to predict a probability of LOS ≥ 2 based on preoperative patient characteristics. Using each model, coefficients were computed for each risk factor based on the training data set and used to create a calculatable ACDF Predictive Scoring System (APSS). Performance of each APSS was then evaluated on a subsample of the data set withheld from training. Decision curve analysis was done to evaluate benefit across probability thresholds for the best performing model. RESULTS In the final analysis, 1,516 patients had a LOS <2 and 643 had a LOS ≥2. Patient characteristics used for predictive modeling were American Society of Anesthesiologists score, age, body mass index, sex, procedure type, history of chronic pulmonary disease, depression, diabetes, hypertension, and hypothyroidism. The best performing APSS was modeled after a lasso regression. When applied to the withheld test data set, the APSS-lasso had an area under the curve from the receiver operating characteristic curve of 0.68, with a specificity of 0.78 and a sensitivity of 0.49. The calculated APSS scores ranged between 0 and 45 and corresponded to a probability of LOS ≥2 between 4% and 97%. CONCLUSION Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting.
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17
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Lopez CD, Boddapati V, Schweppe EA, Levine WN, Lehman RA, Lenke LG. Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers. J Bone Joint Surg Am 2021; 103:1383-1391. [PMID: 33780398 DOI: 10.2106/jbjs.20.01105] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.
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Affiliation(s)
- Cesar D Lopez
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
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18
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Epstein N. Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities. Surg Neurol Int 2021; 12:349. [PMID: 34345489 PMCID: PMC8326133 DOI: 10.25259/sni_509_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background: This is an updated analysis of the morbidity and mortality of cervical surgery performed in outpatient/same day (OSD) (Postoperative care unit [PACU] observation 4–6 h), and ambulatory surgicenters (ASC: PACU 23 h) versus inpatient facilities (IF). Methods: We analyzed 19 predominantly level III (retrospective) and IV (case series) studies regarding the morbidity/mortality of cervical surgery performed in OSC/ASC versus IF. Results: A “selection bias” clearly favored operating on younger/healthier patients to undergo cervical surgery in OSD/ASC centers resulting in better outcomes. Alternatively, those selected for cervical procedures to be performed in IF classically demonstrated multiple major comorbidities (i.e. advanced age, diabetes, high body mass index, severe myelopathy, smoking, 3–4 level disease, and other comorbidities) and had poorer outcomes. Further, within the typical 4–6 h. PACU “observation window,” OSD facilities “picked up” most major postoperative complications, and typically showed 0% mortality rates. Nevertheless, the author’s review of 2 wrongful death suits (i.e. prior to 2018) arising from OSD ACDF cervical surgery demonstrated that there are probably many more mortalities occurring following discharges from OSD where cervical operations are being performed that are going underreported/unreported. Conclusion: “Selection bias” favors choosing younger/healthier patients to undergoing cervical surgery in OSD/ ASC facilities resulting in better outcomes. Atlernatively, choosing older patients with greater comorbidities for IF surgery correlated with poorer results. Although most OSD cervical series report 0% mortality rates, a review of 2 wrongful death suits by just one neurosurgeon prior to 2018 showed there are probably many more mortalities resulting from OSD cervical surgery than have been reported.
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Affiliation(s)
- Nancy Epstein
- Clinical Prof. of Neurosurgery, School of Medicine, State University of New York at Stony Brook, NY, and c/o Dr. Marc Aglulnick, 1122 Franklin Avenue Suite 106, Garden City, NY, USA
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19
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Are outpatient three- and four-level anterior cervical discectomies and fusion safe? Spine J 2021; 21:231-238. [PMID: 33049410 DOI: 10.1016/j.spinee.2020.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSE The present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGN Retrospective cohort study PATIENT SAMPLE: The National Surgical Quality Improvement Program - a large, prospectively-collected registry - was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURES The rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODS Baseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTS In total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONS This present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.
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20
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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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21
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Lopez CD, Boddapati V, Lombardi JM, Sardar ZM, Dyrszka MD, Lehman RA, Riew KD. Recent trends in medicare utilization and reimbursement for anterior cervical discectomy and fusion. Spine J 2020; 20:1737-1743. [PMID: 32562771 DOI: 10.1016/j.spinee.2020.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure. PURPOSE This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates. STUDY DESIGN/SETTING Retrospective analysis of patients undergoing ACDF PATIENT SAMPLE: Medicare patients undergoing ACDF between 2012 and 2017 OUTCOME MEASURES: ACDF volume, utilization rates, and surgeon/hospital reimbursement rates METHODS: This study tracked annual Medicare claims and payments to ACDF surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates. RESULTS A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001). CONCLUSIONS While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.
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Affiliation(s)
- Cesar D Lopez
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY.
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Zeeshan M Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Marc D Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - K Daniel Riew
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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22
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High-risk surgical procedures and semi-emergent surgical procedures for ambulatory surgery. Curr Opin Anaesthesiol 2020; 33:718-723. [PMID: 33002955 DOI: 10.1097/aco.0000000000000918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review evaluates more complex surgical procedures to see whether they might be suitable for ambulatory surgery. Operations that have shown an increasing daycase rate in England include thyroidectomy, joint arthroplasty, spinal surgery and hysterectomy, and these procedures are evaluated. Similarly, there have been recent developments in the management of nonelective ambulatory surgery with more timely throughput and home discharge for suitable patients. RECENT FINDINGS Caveats on patient selection with the development of focussed educational programmes about the proposed operation have assisted with the development of shorter discharge times. Strict antiemetic guidelines, multimodal analgesic protocols and postoperative multidisciplinary follow-up are core components of the pathway for effective ambulatory management. Communication after discharge should include phone calls from the Ambulatory Unit and easy access to the medical staff who conducted their operation. SUMMARY There should be no reason why more complex surgical operations could not be included in a day surgery armamentarium. Similarly, the evidence for more effective use of timely emergency care with shortened length of stay is increasing.
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23
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Lopez CD, Boddapati V, Lombardi JM, Lee NJ, Saifi C, Dyrszka MD, Sardar ZM, Lenke LG, Lehman RA. Recent trends in medicare utilization and reimbursement for lumbar spine fusion and discectomy procedures. Spine J 2020; 20:1586-1594. [PMID: 32534133 DOI: 10.1016/j.spinee.2020.05.558] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements. PURPOSE This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017. STUDY DESIGN Retrospective database study. PATIENT SAMPLE Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files. OUTCOME MEASURES Procedure numbers and payments per episode. METHODS This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements. RESULTS A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, -5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, -0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%). CONCLUSIONS This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries.
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Affiliation(s)
- Cesar D Lopez
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA.
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Nathan J Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Comron Saifi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Marc D Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Zeeshan M Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Lawrence G Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
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24
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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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25
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Weinberg AC, Siegelbaum MH, Lerner BD, Schwartz BC, Segal RL. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020; 17:1025-1032. [PMID: 32199854 DOI: 10.1016/j.jsxm.2020.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Blair C Schwartz
- Division of General Internal Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC, Canada
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26
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Parrish JM, Jenkins NW, Brundage TS, Hrynewycz NM, Singh K. Commentary: Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases. Neurosurgery 2020; 86:E316-E317. [PMID: 31848618 DOI: 10.1093/neuros/nyz529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/04/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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