Five spine surgeons discuss the opportunities for performing spine surgery in outpatient ambulatory surgery centers and where they see the field headed in the future.
This article is sponsored by Amendia.
Q: How has technology and technique development made it possible to bring spine procedures into the outpatient setting?
William Tally, MD, Athens (Ga.) Orthopedic Clinic: The technology allows us to be more efficient during the surgery, decreasing anesthesia time and allowing for less tissue damage. All of this makes the patients' early recovery smoother. These factors make patients more functional within 24 to 48 hours allowing us to perform the same complexity of procedures in the outpatient setting. The minimally invasive procedures are more complex, but they are more efficient and less destructive.
Ashish Sahai, MD, Spine & Orthopedic Center, Deerfield Beach, Fla.: The OLLIF is ideal because there is less tissue disruption, operative time and bony resection. It can also be combined with other minimally invasive techniques as necessary, serving a dual purpose.
Gerald Schell, MD, Saginaw (Mich.) Valley Neurosurgery: The OLLIF is done with very little tissue damage. The standard surgeries or interbody fusions require a large incision, removal of major facet joints, creating scarring around the nerves. This iatrogenic damage makes it difficult to send the patient home that day. The OLLIF procedure is a lateral interbody technique that doesn’t require the removal of any bone. There is very little trauma to any tissue and the work performed directly addresses the patient’s pathology.
Q: What are the advantages to performing spinal cases as outpatient procedures?
Randolph Bishop, MD, Neurological Institute of Savannah (Ga.): The advantages of using an outpatient center for the performance of spine surgery yields similar advantages to what has been demonstrated in other subspecialties. An outpatient surgery center provides for a more personal level of patient care which is a strong positive for both patients and surgeons.
The care delivered is much more specialized and the center can be more focused on a specific specialty which leads to a more efficient and effective delivery of service.
Bobby Bhatti, MD, Rockdale Orthopedic Center, Conyers, Ga.: There are also advantages to the ASC setting for surgeons. Our ASC was critical in attracting patients to our practice. Patients prefer the ASC setting and it’s more efficient for both patients and physicians. Given the lower risk of infection, lower need for narcotic pain relief post-procedure, and higher patient satisfaction ratings, I try to use the ASC for as many patients as medically appropriate.
GS: One key advantage of this is surgery is reduced anesthesia time. Since the procedures does not involve dissecting or retracting tissue, the patients spend less time under anesthesia, experience less blood loss, thus substantially lowering the risk of the surgery. Furthermore, the outpatient setting is far less costly than the hospital setting.
Q: Excellent point — what exactly is the economic impact of being able to perform spinal surgeries in the outpatient setting?
RB: There is no doubt that performing spinal surgery in an outpatient setting provides marked reduction in cost of care. Not only is the actual surgery less expensive secondary to better efficiency, there are no additional costs that may come about with hospitalization such as nosocomial infections and medication errors.
BB: With so much focus on the cost of medicine today, many procedures will move to the outpatient setting as insurance companies, employers and patients push back on expensive hospital stays. Overall, the migration to outpatient surgery is positive in a time where so much emphasis is being placed on medical economics.
WT: In the future, spine surgery will become more of a cash business. You can control cost much more effectively in the outpatient setting which provides more value to the patient. Once the value of the procedure is known by the patient, volume will increase exponentially.
Q: Medicare doesn't currently reimburse for outpatient spine surgeries in ASCs. Are commercial payers any better?
BB: Yes, that is true, Medicare currently does not cover spinal fusion in the ASC setting. Many times, commercial insurers will not approve inpatient procedures, but will approve the same procedures in the outpatient setting. If we can safely do a procedure, such as OLLIF, in the outpatient setting, and have patients return home the same day with a much lower risk of post-operative complications, then more insurance companies will move in this direction. Spine surgeons will need to adapt to the movement of these types of procedures to the ASC.
Q: What differences are there for surgeons when they first start doing cases at the ASC as opposed to the hospital?
AS: Surgery centers are usually run differently than hospitals. Typically there are fewer resources available and there is emphasis on only using what is needed for the surgery. It is also important to make sure there is adequate follow-up with patients postoperatively. Finally, it is important in the ASC to be comfortable and familiar with equipment and instrumentation provided by the facility.
Q: Many surgeons are considering the adoption of new spine surgeries and minimally invasive techniques in to their practices. Do you have any tips for them?
GS: As surgeons start to move minimally invasive spine surgery to the outpatient setting, there should be adequate training, including case observations, with experienced surgeons. During the first few procedures in the ASC, surgeons should have access to teaching physician to answer any questions that may develop while observing the patient. Patient selection is a key factor in successful outpatient surgery. Knowing which patients are candidates, and more importantly which patients are not, is critical in the outpatient setting.
WT: Patients needed to be educated on the level of pain they will experience, what they are expected to do postoperatively, and what is within the range of normal with regards to pain. Sometimes patients think that because their surgery is performed in the outpatient setting, their pain levels should be lower, and they panic.
When patients know what to expect, it greatly reduces postoperative problems with pain. Let them know they can still contact your office after surgery with any questions or worries – this reduces the urge to head straight to the ED if they become concerned about their pain levels after returning home.
Q: Where do you see the most opportunity for growth in the outpatient spine surgery center setting in the future?
AS: Endoscopic spine surgery is become an interesting avenue that is being reevaluated after falling out of favor. Simple decompressions and microdiscectomies are moving to the outpatient departments at hospitals, so the ASC setting is the next logical choice. One-level ACDF procedures are being routinely performed in the outpatient setting, but the biggest opportunity is lumbar fusions in non-complex patients.
RB: Most routine spinal surgeries will be performed in an outpatient setting in the future. Surgeons that do not prepare for this will be unable to compete effectively against those that do and these same surgeons may in fact be viewed as "less capable" as a result.
WT: As more surgeons are trained in this setting, we are going to see a higher volume of both cervical and lumbar procedures performed in the outpatient setting. A bigger opportunity in the outpatient setting are lumbar procedures. When surgical techniques can be streamlined enough to reduce anesthesia time, and instrumentation is developed that can reduce the number of steps in a procedure (like OLLIF), we will facilitate the move of spinal fusions to the outpatient setting.
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