10 things to know about spine surgery in ASCs

Here are 10 key facts and studies on outpatient spine surgery and spine procedures in ASCs.

1. Outpatient spine surgery growth in hospital outpatient department is growing faster than in ASCs. A December 2017 article in Spine found:

• Outpatient hospitals reported the largest growth in lumbar decompressions at the first level, growing from 18.7 percent of procedures to 68.5 percent.
• Posterior cervical decompressions without facectomy discectomy at the first level jumped from 0 percent to 46.7 percent in the hospital outpatient setting.

At the same time, lumbar decompression laminotomy first level in the ASC jumped from 0.7 percent in 2003 to 10.6 percent in 2014 and posterior cervical decompression laminotomy increased from 0 percent to 23.4 percent.

Study authors theorized, "one possible reason for this trend may be that surgeons feel that this safety may not be comparable to that of other outpatient procedures."

2. Spine surgery is a high cost procedure, but ASCs report an annual cost savings of $140 million for spine surgery, according to a study published in Neurosurgery.

3. There have been two studies examining cervical arthroplasty in ASCs. The cost of outpatient cervical arthroplasty was 62 percent less than single-level outpatient anterior cervical discectomy and fusions as well as 84 percent less than inpatient procedures. The studies also found clinical quality and did not report serious complications such as hematoma or severe pain.

4. There are more than 100 ASCs that focus on spine surgery, and procedures such as lumbar discectomies and posterior cervical foraminotomy are commonly performed on an outpatient basis. The literature supports transitioning ACDF to the outpatient setting as well, and evidence suggests minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusions could go outpatient in larger numbers with the appropriate patient selection.

5. In May 2017, a panel of three neurosurgeons, three anesthesiologists, one orthopedic spine surgeon and a registered nurse conducted a three-round modified-Delphi method to generate best practice statements for spine surgery in ASCs. The statements included:
• Patient selection — the patient's age, BMI over 35 kg/m2 and previous anterior surgeries shouldn't preclude them from outpatient surgery. However, patients with severe cardiopulmonary comorbidities aren't good candidates for outpatient surgery.
• Pain management — to avoid opioid use, the best practice is employing short-acting anesthetic agents for outpatient spine surgery patients. Preoperative analgesia plans are necessary and the panel recommended using mild analgesics for initial pain control before administering opioids for persisting pain.
• Patient education — the best practice is for healthcare providers to educate patients and caregivers about the goal of surgery, procedural details and anesthesia-related issues. Additional emphasis on expectations for postoperative care such as smoking cessation, medication use, emergency care access, warning signs and wound care are recommended.
• After care — panelists recommended ASCs use backed discharge checklists from first- to second-stage recovery; 80 percent recommended observing patients for at least three hours postoperatively and all backed postoperative follow-up calls from a nurse the day after surgery.
• Payment — be proactive in payer negotiations and establish procedure-specific reimbursement rates for your facility. It's also a best practice for ASC staff to confirm the patient has coverage for spine surgery in the ASC setting and notify patients of their cost obligations. ASCs can establish policies for self-pay patients.

6. For 2018, CMS added two cervical spine procedures to the ASC payable list: cervical arthroplasty and two-level cervical arthroplasty.

7. Outpatient spine surgeries have grown significantly in the past decade, with nearly 45 percent of spine cases done outpatient in 2015. Of the around 650,000 to 700,000 spine surgeries performed per year, around 280,000 to 300,000 are done outpatient.

8. Bundled payments are coming to spine surgery, and outpatient centers fit within the value proposition. A 2014 study in Spine shows 30-day bundles range from $11,180 to $107,647, with 76 percent of the bundle going to hospital payments on average.

9. One criticism of the ASC industry is physician ownership; does owning the ASC mean surgeons will unnecessarily increase surgical volume? Philadelphia-based Rothman Institute surgeons aimed to track that trend. The 75-orthopedic surgeon group tracked procedure volume from January 2010 to March 1, 2015, during which time the practice purchased ownership stake in a hospital and three ASCs.

The average increase in cases per year for equity partners was 1.51 cases; two years after investing in the physician-owned specialty hospitals, there was a decrease in the number of cases per surgeon per month. "In a well-established large orthopedic practice, surgeon ownership of a hospital or ASC does not lead to an increase in surgical volume," the study authors concluded.

10. A December 2017 study published in Spine found, among Tricare beneficiaries, outpatient spine clinic utilization was associated with reduced emergency department visits after spine surgery.

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