Findings Support Safety of Outpatient Anterior Cervical Discectomy and Fusion
Study Coauthor Matthew J. McGirt, MD Comments
Anterior cervical discectomy and fusion (ACDF) can safely be performed in the outpatient setting, according to an analysis of 1,000 consecutive cases performed by surgeons at Carolina Neurosurgery and Spine Associates (CNSA) in Charlotte, North Carolina. The researchers found a low rate of surgical complications—1%—in the outpatient setting, as reported in the June issue of Global Spine Journal.
"ACDF has traditionally been performed in the inpatient setting because of the potential for life-threatening perioperative complications such as neck hematoma that may compromise the airway," said coauthor Matthew J. McGirt, MD, neurosurgeon at CNSA, and Adjunct Associate Professor at the University of North Carolina, Chapel Hill. "Despite the relatively low incidence of these morbid perioperative complications, hospitals have been reluctant to move the procedure to the outpatient setting because of the severity of this condition and lack of evidence supporting the safety of outpatient ACDF," Dr. McGirt explained.
"Traditionally, surgeons have kept patients in the hospital one or two days to watch for these complications and treat them when necessary," Dr. McGirt said. However, the evidence to date has suggested that when these life-threatening complications occur, they tend to occur within the first few hours after surgery rather than over the following 24 to 48 hours, he said.
Because of these published time trends of perioperative ACDF complication, CNSA has made outpatient ACDF with a 4-hour observation window in recovery the standard of care for all of their patients who have an American Society of Anesthesiologists [ASA] Class I, II, or III, Dr. McGirt explained.
Outcomes from 1,000 Consecutive Patients Receiving Outpatient ACDF
The study compared outcomes from 1,000 consecutive patients who underwent outpatient ACDF at Carolina Center for Specialty Surgery (CCSS) ambulatory surgery center with outcomes from 484 patients who underwent inpatient ACDF at Vanderbilt University Hospital in Nashville, Tennessee. The majority of outpatients were in ASA Class II (74.1%); nearly 20% were in Class I and relatively few were in Class III (6.4%).
Among the outpatient group, 8 patients (0.8%) were transferred to the hospital postoperatively for pain control (n=3), chest pain and electrocardiogram changes (n=2), intraoperative CSF leak (n=1), postoperative hematoma (n=1), and postoperative weakness and surgical reexploration (n=1). No deaths occurred following surgery, and the 30-day hospital readmission rate was 2.2%.
The outpatient and inpatient groups showed a similar 90-day surgical morbidity for both 1-level and 2-level ACDFs. Neck hematoma occurred in 2 patients who underwent outpatient ACDF and 1 patient in the inpatient group.
"With our protocols, this procedure can be done safely in the outpatient setting," Dr. McGirt said, adding that the surgeons have now treated up to 1,500 patients with this protocol with no catastrophic complications occurring outside of the 4-hour window. He believes that the findings are reproducible at other surgical centers that use the same selection criteria, have experienced surgeons, and provide the same perioperative management and observation window.
Findings Speak to Issues of Cost Containment and Healthcare Reform
"The findings speak to the broader issues of cost containment, quality improvement, and healthcare reform," said Dr. McGirt. "One of the most palpable and greatest opportunities for cost control is moving inpatient spine surgery to the outpatient setting whenever appropriate."
"While the vast majority of innovation in spine surgery in the past two decades has been on the technological side, I believe the real innovation for this next decade is going to be on the health services delivery side—that is, more efficient and effective ways to deliver care for the entire service line, not just in the silo of the operating room," Dr. McGirt said.
"The cost savings that the United States would have annually if 80% of ACDFs were moved to outpatient setting is astronomical. This is a tremendous opportunity. This is a sentinel paper demonstrating that insurance companies as well as patients and employers who pay for health care could save a lot of money without sacrificing quality with outpatient ACDFs. That is healthcare value, that is innovation."
In addition, the patient experience "is fantastic," Dr. McGirt said. The outpatient surgery is performed in a small setting that is not intimidating, and service is provided in an expedited, streamlined, personalized care experience. Our highest patient satisfaction scores are from the outpatient surgery center setting.