Outpatient spine is on track to becoming the new normal, and ASCs are on the forefront of the transition. More than 190 ASCs in the U.S. now offer minimally invasive spine surgery, a significant increase in the last decade.
Outpatient surgery migration has been spurred by recent advances in surgical techniques, anesthesia and postoperative rehab. These developments have resulted in lower-cost, shorter procedures with less blood loss and fewer complications, allowing surgeons to send patients home safely within 24hours of surgery.
Three spine leaders — Nitin Khanna, MD, of Spine Care Specialists in Munster, Ind.; Richard Kube, MD, of Prairie Spine & Pain Institute in Peoria, Ill.; and Richard Jeffords, MD, of Resurgens Orthopaedics — joined Becker’s ASC Review to discuss the migration of spine procedures to ASCs, and what they predict in the coming years.
Editor’s note: These responses were edited lightly for brevity and clarity.
Question: Where do you see the future of spine in ASCs headed?
Dr. Nitin Khanna: There is only one direction for ASCs — up. Convenience, cost and quality are the elusive ingredients for healthcare, and all [are] captured with the ASC physician ownership model. Hospital systems will need to adopt this strategy in order to remain market-competitive and grow.
Dr. Paul Jeffords: Already over the last five to 10 years, we’ve seen a migration of spine cases from the hospital to the surgery center. I think that as time goes on, what we’ll see is more and more complex cases being transferred as surgeons and anesthesiologists and nursing staff get more comfortable managing those patients on an outpatient basis.
Dr. Richard Kube: Clinically, most things are feasible to perform in an ambulatory surgical facility. Yet, we see Medicare shifting different codes back out of ambulatory settings. If and when the self-funded, self-insured market wakes up to the money that they’re blowing needlessly, I think we will see enormous volumes of cases starting to move in the ambulatory setting. Until then, I think the hospital industry and the insurance industry that profits by keeping those cases in their current environment will continue to do what they can to make sure the status quo remains.
“Anesthesia techniques have improved, surgical techniques have improved and patient education has improved to the point that the vast majority of spine procedures can be done in an ambulatory center.”
Richard Kube, MD, of Prairie Spine & Pain InstituteRichard Kube, MD, of Prairie Spine & Pain Institutein Peoria, Ill.
Q: What spine procedures and technologies are moving from the hospital to the ASC?
Dr. Khanna: We are seeing previously unheard-of routine lumbar fusions now performed in an outpatient setting. Disc replacement really embodies the true advances that we have made in spine during my 20 years of private practice. We can now decompress the neural elements and restore motion with the patient at home within two to three hours and off pain medication within two to three days. It is remarkable how far we have come.
Dr. Jeffords: From a technology standpoint, obviously, the minimally invasive implant systems have allowed us to do these cases on these patients in an outpatient setting. The minimally invasive nature of these cases leads to less pain, quicker recovery and less blood loss. It’s a better experience for the patient. Additionally, image guidance and navigation —as surgeons are taking these more complex minimally invasive lumbar fusions to the ASC, the navigation and imaging will naturally migrate with those cases.
Dr. Kube: Anesthesia techniques have improved, surgical techniques have improved and patient education has improved to the point that the vast majority of spine procedures can be done in an ambulatory center. We do those regularly, especially when you have an overnight capacity. If you don’t have an overnight capability, that does change things quite a bit. You do have to worry about swelling, you do have to worry about some different aspects that would limit significantly the types of cervical spine cases I would do if I didn’t have the ability to have somebody overnight. I know different people try to look for technology to get there, but I think most of that technology is already here. There are things that will continue to make surgeons’ lives easier and make it more feasible to perform a variety of things. Those will just improve what’s already there, whether it’s imaging techniques or navigational techniques. Those will just continue to improve things.
Q: What innovations do we still need to move more cases into the ASC?
Dr. Jeffords: The biggest innovation, I would say, is not really a technical innovation, it’s more of a thought process. One of the things that I say when I give talks to surgeons at meetings about how to move cases from the hospital to the surgery center is your thought process — preparing yourself, preparing the patient and preparing the staff. The innovation is basically changing the way you think about how to manage these patients, changing the patient’s expectations.
Dr. Khanna: I think revision surgery and lateral surgery are being performed outpatient, although the numbers are small. One of the biggest obstacles remaining is training, as many of the prestigious spine fellowships offer minimal if any outpatient surgery training. A young surgeon will always feel more confident operating the way their mentor operated. It will be incumbent on fellowships to either directly offer or partner with surgeons that are performing routine outpatient spine surgery. This is our best opportunity to continue to move the field of spine surgery forward.
Dr. Kube: From my vantage point, I don’t think there are necessarily any technical surgical advances, I think most of the advances are really education on the financial models that are out there and an understanding of how access can be obtained for a great variety of things. As you start looking at the system as something new, in a different light, the costs continue to go up. There’s not really a lot of true pressure for any of the current industries to drop those down.
Q: There are many spine surgeons across the U.S. considering taking more complex cases to the ASC. What do they need to know?
Dr. Khanna:Take your time. Build your practice. Build your skill set. Start small and build relationships with the ASC staff and anesthesia. Do the smaller cases then build to the instrumented cases. Once you have become facile with the more straightforward cases, it will be a natural progression to take on the more challenging/complex cases. It is patient first and foremost. Make sure the patient is onboard with what outpatient surgery has to offer and never talk a patient into an outpatient surgery.
Dr. Kube: Take a scientific approach. The first case I did in an ambulatory environment wasn’t a complex case. You need to really study the cases that you’re doing. Be honest about your outcomes. Look at the numbers, and run the numbers. What’s the patient’s pain like? When are they ambulating? I think you really need to be honest with the types of procedures you do. How mobile are these people? How can they get up and move around? What is my real complication rate? How often do I have to transfuse people? If you have a patient who you’re pushing the envelope on the health of the individual, you’re going to have a problem. Respect your anesthesia team, take their advice, talk to them about these people, make sure that they’re comfortable with who you’re signing up for an operation. Make sure that they’re reliable.
“Take your time. Build your practice. Build your skill set. Start small and build relationships with the ASC staff and anesthesia.”
Nitin Khanna, MD, of Spine Care Specialists in Munster, Ind.
Q: What are the benefits of the ASC for both the surgeon and the patient?
Dr. Jeffords:From a patient standpoint, it’s a much more patient friendly environment. It’s a much more efficient environment. When you go to a surgery center that specializes in one area of expertise, the patients feel like they know that everybody in that facility is there for one reason — to do orthopedic, and spine cases. We’re not focusing on 20 different things. It’s a very patient and family-friendly environment. Also, the infection rates tend to be lower in the surgery center. From a surgeon standpoint, the ASC is more efficient. We get special attention from the staff, and the efficiency is much greater than what we experienced in the hospitals in terms of turnover time.
“When you go to a surgery center that specializes in one area of expertise, the patients feel like they know that everybody in that facility is there for one reason — to do orthopedic, and spine cases.”
Richard Jeffords, MD, of Resurgens Orthopaedics
The opinions of Dr. Nitin Khanna, Dr. Paul Jeffords and Dr.The opinions of Dr. Nitin Khanna, Dr. Paul Jeffords and Dr.Richard Kube are of Dr. Khanna, Dr. Jeffords and Dr. Kube and not necessarily those of Stryker.