At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 15, Alan Villavicencio, MD, of Boulder Neurological & Spine Associates, gave a presentation titled "Minimally Invasive Outpatient Lumbar Fusions — A Study on Clinical Outcomes in the ASC." He discussed his experience performing spine surgery in an ASC and outcomes data collected over several years.
1. Factors contributing to the move toward outpatient spine surgery. Dr. Villavicencio discussed several factors contributing to the move toward performing spine surgery in the ASC, including:
• Increasing cost of healthcare
• Less invasive surgical techniques
• Advancements in anesthesia
• Growing confidence in medical staff and surgeon abilities
• Increased complications in the hospital setting
Minimally invasive spine surgery allows surgeons to perform a procedure with less trauma, blood loss, epidural scarring and postoperative pain. Recovery times are also quicker with the less invasive procedures.
2. ASC environment is more efficient and cost effective. In one of his studies, Dr. Villavicencio discovered that patient stays at the hospital were longer than at the surgery center for the same procedures. "If you take the same surgeon, surgical assistant and technique from the ASC to the hospital, the hospital staff aren't trained to encourage patients to get out of there," he said. "It takes 21 hours for patients to leave the hospital, compared to four in the ASC."
He also compared costs for patients undergoing spinal fusions in both environments. The cost analysis for the average inpatient surgery in the hospital for a one-level transforaminal lumbar interbody fusion was $45,184, compared to $29,983 in the ASC. These costs include implants with rhBMP-2 to promote fusion.
3. 23-hour stays are possible by doing big cases later in the day. During his years in practice, Dr. Villavicencio found that it works better to perform the bigger cases later in the day so patients who need 23 hour stays can spend the night without having to leave the center in the early hours of the morning. "We used to do the big cases in the morning and smaller cases later, but we found that if a patient checks in at 6 am, you have to have them out the door by 5:59 am the next morning," he said. "Rolling patients out at that time isn't so good, so we reversed it; the big cases are performed later in the day and smaller cases are performed in the morning."
4. Patients are more mentally prepared for the ASC experience. Patients should understand how long they will be staying at the center postoperatively. If they know they'll be leaving, and understand they will be in some pain, they are more likely to have a smooth transition out of the surgery center. "The biggest hurdle to doing these procedures in the outpatient setting is mental preparation," said Dr. Villavicencio. "When you tell the patient they are leaving in one day, they'll be ready to go in one day. It's also good to have them mentally prepared because if you don't, they'll give you a bad patient satisfaction rating."
5. Refined patient selection for ASC cases. Not every patient will be a good candidate for spine surgery in the ASC. "Appropriate patient selection is paramount to good outcomes," said Dr. Villavicencio. "There should be an absence of significant comorbidities, younger age and the ability to have adequate care after surgery. For these patients, it's safe and efficacious to perform spine surgery in an outpatient setting and there is a cost savings."
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