Paradigm Shift to Outpatient Spine Surgery Centers

Highlight From the 33rd Annual Meeting of the North American Spine Society (NASS 2018)

Peer Reviewed

Among the many changes ushered in by the Affordable Care Act (ACA) is a focus on patient outcomes and the economics of health care in addition to clinical outcomes, Jeffrey S. Roh, MD, MBA, MSc said at the NASS 2018 Meeting held September 26-29 in Los Angeles, CA. Ambulatory surgery centers (ASCs) have evolved as one method to achieve these goals, Dr. Roh told the audience.
Operating room, surgical suiteThe shift toward ambulatory surgery centers stems from the ability to perform spine surgery using minimally invasive techniques and technologies. Photo Credit: 123RF.com.“There is definitely a shift toward ASCs because we can show that there are maintained or improved clinical outcomes, increased patient satisfaction, and reduced overall costs,” said Dr. Roh, who is Director of Minimally Invasive Spine Surgery at the Swedish Neuroscience Institute in Seattle. This shift is facilitated by improvements in surgical and anesthetic techniques, coupled with research demonstrating the benefits of awake spinal fusion and thoracic and lumbar spine surgery performed using local anesthetic.1

The shift toward ASCs also stems from the ability to perform “minimally invasive surgical techniques with lower morbidity, decreased post-operative pain, shorter hospitalization (if any), and improved functional and clinical outcomes,” Dr. Roh said. These minimally invasive techniques for spine surgery include cervical/ thoracic/ lumbar decompressions including multiple level microdiscectomies with one incision, and one or two level cervical/lumbar instrumented fusions.

While most multilevel fusions cannot yet be performed as an outpatient procedure currently, Dr. Roh pointed to the recent decision by the Centers for Medicare and Medicaid Services to cover total knee and hip replacements performed at ASCs as an example of how less invasive procedures can be used to perform complex surgeries in the outpatient setting. He believes that this same evolution is right “on the horizon” for more complex spine surgeries.

Assessing Best Practices to Improve Outpatient Spine Surgery Outcomes
At the Swedish Neuroscience Institute, Dr. Roh and his colleagues track a variety of metrics to assess best practices in outpatient spine surgery including patient demographics, clinical outcomes, work status before and after surgery, insurance status, patient satisfaction, and post-operative pain management. Patient demographics include procedure type, gender, and average age, Dr. Roh explained.

Clinical outcomes are documented at various time points including pre-operatively, the day of surgery, and days, weeks, and months after spine surgery. Case volume per surgeon and the duration of surgeries also are accounted for to determine the economics of care and where gaps in time occur. Patient reported outcomes are tracked using an app with post-operative compliance rates between 95% to 100%, Dr. Roh told the audience.

“We also take a look at pre-operative work status, because the primary reason why that is important is we want to know if the intervention helped patients with respect to their post-operative return to work status,” Dr. Roh said.

Insurance provider breakdown by patient plan and type accepted by individual surgeons also are evaluated. In addition, profit and loss (P&L) metrics are analyzed to determine which procedures are best performed in an outpatient setting and are calculated based on surgery center, surgeon, and insurance status, Dr. Roh said.

Patient satisfaction with pain treatment, as well as average satisfaction score by surgeons are monitored following spine surgery. The data also allows for extraction of patient satisfaction by surgeon as well as which components of their care patients are most satisfied with, Dr. Roh explained. This way, we can determine “which surgeons have higher satisfaction scores, and are there things that we can learn from them?”

Consequences of Post-Operative Pain in Outpatient Spine Surgery
Post-operative pain is an important factor to consider when transitioning to an ASC, as inadequate pain relief is a top reason for unplanned hospital readmissions after spine surgery.

“The consequences of post-operative pain can lead to delayed ambulation and daily functioning, longer post-surgical recovery time, increased length of stay, higher incidence of surgery-related complications and hospital readmissions, prolonged patient suffering, and unrelieved acute post-surgical pain,” Dr. Roh told attendees at NASS 2018.

While opioids are commonly used for post-operative pain management as they are relatively effective with a low cost, negative side effects include fall risk, adverse events in over 10% of patients, increased length of stay, and other societal burdens adversely affecting the current opioid epidemic plaguing the US, Dr. Roh said. When opioids are used in patient-controlled anesthesia (PCA), dosing and monitoring errors may occur leading to an increased risk of respiratory depression.

Dr. Roh said that his life science incubator, IntuitiveX, has been developing a digital platform to gather metrics on what type of opioids are being prescribed for individual surgeries to better understand how prescribing patterns relate to patient outcome and satisfaction scores.

He suggested that non-opioid strategies should be standardized in the management of post-surgical pain following outpatient spine procedures. These multimodal strategies include non-steroid anti-inflammatory drugs, non-opioid based analgesics, gabapentoids, as well as anesthetics delivered via epidural and continuous infusion.

Dr. Roh’s post-operative rehabilitation protocol is “relatively simple” and includes mobilization immediately after the surgery regardless of the type of procedure as long as the patient does not have any instability. At 4 to 6 weeks post-operatively, patients begin low-impact aerobic activities, followed by higher impact aerobic activities (eg, running/ jumping/ sports) at 3 months. Full activities are resumed within 6 to 12 months, and post-operative CT scans are often utilized to confirm bone healing in patients who undergo spinal fusion surgery, Dr. Roh concluded.

Disclosures
Dr. Roh disclosed the following relationships: Royalties: Stryker Spine; Stock Ownership: Advanced Biologics, Artoss, IntuitiveX, Innovasive; Consulting: Stryker Spine, J&J DePuy Synthes; Speaking and/or Teaching Arrangements: Stryker Spine, J&J DePuy Synthes; Trips/Travel: Stryker Spine, J&J DePuy Synthes; Board of Directors: Arthritis Foundation.

Updated on: 10/30/18
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Jeffrey S. Roh, MD, MBA, MSc
Director
Seattle Minimally Invasive Spine Center
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