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5 Things to Know About Acquiring an O-Arm for Spine ASCs

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Michael J. Musacchio, Jr., MD, and John H. Peloza, MD, opened their ambulatory surgery center, Institute for Minimally Invasive Surgery, last October with a vision of incorporating emerging technologies that would rival any hospital operating room. This vision included the purchase of an O-arm in their initial budget. Dallas-based IMIS, which is affiliated with Meridian Surgical Partners, is the first and only surgery center in the United States to purchase an O-arm.

"We've built our model focusing on the highest quality patient care using evidence-based medicine and results-driven decision making," says Dr. Musacchio. "Our practice has been successful because patients are happy with their outcomes. Purchasing an O-arm for our surgery center aids us in the delivery of the same outcomes in an ASC as in the hospital setting."

Dr. Musacchio discusses five points on bringing O-arm technology into an ASC.

1. It allows surgeons to recreate hospital ORs in the ASC.
Hospitals with advanced spine care programs are increasingly acquiring O-arms to enhance their surgical capabilities. This technology allows surgeons to take intraoperative fluoroscopic images. The machine develops two and three dimensional images of the patient's anatomy, allowing surgeons to navigate the procedure more accurately and improve precision in implant placement. The images can be updated during to operation to improve landmark identification. At the completion of the surgery the images are updated again to confirm the accuracy of implant placement and extent of decompression before waking the patient from sedation.

"With this technology we can perform more complex surgeries through minimally invasive techniques with greater safety and accuracy," says Dr. Musacchio. "The image is a virtual representation of the patient's anatomy at the time of surgery, enabling us to plan the least invasive approach before making the incision. The benefit is that we have the ability to do more complex cases, including fusions, while minimizing blood loss and tissue disruption."

At IMIS, Dr. Musacchio performs a wide spectrum of procedures from small percutaneous surgeries to more complex procedures like lumbar fusions. The patients are all discharged within 23 hours, due in part to the minimally invasive approach with the O-arm and advancement in postoperative pain management.

2. Surgeons can check accuracy before patients leave the OR. Traditionally, surgeons depend on two dimensional fluoroscopic images at the end of the surgery to evaluate implant placement; however, there are limits to this technology. With O-arm technology, surgeons can confirm implant placement with a 3-D reconstruction comparable to a CT scan

"Before leaving the operating room we obtain one last O-arm spin so we know exactly where the instrumentation is," says Dr. Musacchio. "This is a huge benefit because we can spin the O-arm while the patient is still in sterile conditions and under anesthesia. If a screw is not in ideal position we can reposition it right then. Therefore, we are confident of where the instrumentation is and what we've done."

3. Incorporate equipment purchase into your business plan.
O-arm technology is a significant expense for any surgery center, but the expense can be recouped in a short time depending on the number of spine cases surgeons can bring into the center. Dr. Musacchio and Dr. Peloza built the cost into their budget when building the center because they knew it would be an integral part of the care they provide.

"We opened our surgery center last October and in the planning phases we built the O-arm into our budget," says Dr. Musacchio. "We were willing to make the capital investment for our center because we can perform more complex cases, leading to a higher revenue per case average at the ASC. We understood that providing the highest level of care available would cost more money upfront, but we make that up in revenue and successful patient outcomes."

Spine surgery can be one of the more lucrative procedures in a surgery center. Due to the nature of the procedures, it reimburses higher than other less complex procedures. However, insurance companies are tightening their guidelines for approving some spinal surgeries such as fusions.

"The best way to make sure your surgeries are covered is to have clear indications," says Dr. Musacchio. "We're having trouble with getting approval for some spinal procedures for patients with degenerative disc disease, which isn't necessarily a bad thing. We are doing what is best for the patients, which often is following a conservative approach to care."

The O-arm doesn't increase approval for spinal fusions, but surgeons can use it when approval is granted for the primary procedure. "When we built our center, we didn't want to just perform simple discectomies and small surgeries; we wanted to be able to perform surgeries across the spectrum including spinal fusions, disc replacements, motion preserving instrumentation and revisions surgeries," says Dr. Musacchio. "In the hospital, we use an O-arm for those procedures, so we wanted an O-arm for our surgery center."

4. O-arm technology can be an attraction for patients and physicians.
Surgery centers often have the same problems as community hospitals when purchasing O-arm technology: it's expensive and the center must have a high volume of spine surgeries to justify the purchase. However, the technology can be attractive to patients and appealing to physicians who want to take their cases outpatient.

"The O-arm opens up all types of possibilities for surgery centers," says Dr. Musacchio. "It's a good marketing tool for the center because it can drive a campaign to increase patient flow. The O-arm can also be a driving force in recruiting surgeons to join the center."

In addition to attracting spine surgeons, the O-arm technology could become useful in other specialties with complex cases such at otolaryngology and orthopedics. For now, IMIS includes two spine surgeons and three pain management physicians, but Dr. Musacchio says they are open to expanding.

"We are open to growth in different specialties, but our focus is on minimally invasive procedures," says Dr. Musacchio. "We want to work with surgeons in other specialties that share our vision of providing the highest quality, evidence based, results driven care with state of the art technologies. We made an investment in the O-arm technology to make sure we are following that vision."

5. Not every patient is good for the outpatient setting. Even though O-arm technology can improve the procedure, not every patient is a good candidate for outpatient surgery. Patients with extensive medical comorbidities or those in need of extensive procedures that will take more than a 23 hour recovery before discharge should be performed in the hospital instead.

"Knowing your limitations pre-operatively is key. We don't perform outpatient surgery on patients with extensive comorbidities or those who need extensive multilevel surgeries. These patients typically require a longer post-operative stay and are better suited for the in patient hospital setting," says Dr. Musacchio. However, Dr. Musacchio estimates that about 90 percent of the procedures he performs in his practice are done in an outpatient setting.

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