Lessons on Performing High-Acuity Spine Cases in the ASC

At the 20th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, Robert Bray, Jr., MD, neurological spine surgeon, and Karen Reiter, COO of DISC Sports and Spine Center in Newport Beach and Beverly Hills, Calif., discussed high-acuity spine procedures in the ambulatory surgery center.

"One of my philosophies is the way that a surgical center can make money is by pushing the envelope by doing things that are new," said Dr. Bray. He said 75 percent of his DISC's profit at the end of the day comes from doing complex spine procedures.

For years, Dr. Bray has predicted that spine cases in the outpatient setting will match those in the inpatient setting by 2014. While the number in the outpatient setting is certainly on the rise, Dr. Bray said it's moving a little slower and he's not quite sure it will match by 2015.

As they take on more complex cases, Dr. Bray said ASCs must continue to emphasize safety, quality and cost efficiency while providing a patient-centered environment. "I believe this will be the winning combination that keeps us alive," he said. Infection control is a huge benefit to performing these cases in an ASC. "We've had zero reported infections after doing about 8,000 spine cases," said Dr. Bray.  

DISC typically keeps patients with complex cases for 23 hours, which Dr. Bray said allows staff to provide about higher level of service for shorter period time than the patient might experience in a hospital. "For 23 hours, we treat everyone like an [intensive care unit] patient," he said. "They're getting that level of care. That's a higher level of service." Dr. Bray said this focused, attentive care is what allows him and his team to perform more high-acuity cases.

Performing these cases in the outpatient setting also means surgeons are more likely to take the least invasive approach possible. This can bring down the cost of some surgical supplies, as Dr. Bray mentioned. "When we look at our case mix surgically, we have dramatically lower rate of pedicle screws and more emphasis on minimally invasive procedures," he said.

Dr. Bray divides case mix by simple, middle and complex. Simple includes procedures like kyphoplasty and posterior cervical foraminotomoy. Middle includes cervical laminoplasty and anterior cervical discectomy and fusion (up to three levels). Complex includes disc replacement, anterior limbar interbody fusions, intradural tumors, Arnold Chiari decompression, fusions (multiple levels), and lateral approach to an interbody fusion.

Ms. Reiter discussed some common challenges with high acuity cases. "You have to plan for the worst case scenario and be able to handle it," said Ms. Reiter. Before admission, she said one of the biggest predictors for a bad outcome is the patients' comorbidities It's not necessarily the complexity of the case.

This just emphasizes the need for staff to get a comprehensive patient history. It also means the surgeon must be cognizant of the nature of the comorbidities they're taking on. "You need a champion who is liberal enough to accept big cases, but will say no, regardless of the reimbursement," if the comorbidities mean the case would be better suited for the inpatient setting, she said.

More Articles on Spine Surgery and ASCs:

6 Big Trends in Spine Surgery Reimbursement
Driving Value in Spine Care: Outpatient Spine Surgery
8 Factors Impacting Spine Surgery Coverage Rates

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