Seven spine surgeons discuss whether or not they are performing spine surgery in outpatient settings and why. Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: How are you approaching bundled payments?
Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, Nov. 13, at 5 p.m. CST.
Michael Duffy, MD, Orthopedic Spine Surgeon, Texas Back Institute, Dallas: Outpatient services have significantly increased over the last decade. The driving force has been multi-factorial with third party payers leading the charge to direct certain procedures to a more cost-effective environment. Physician ownership in outpatient facilities has also directed procedures to ambulatory surgery centers, which creates a minor conflict of interest in my opinion. Where does the line belong?
Traditionally, spine surgery has been an inpatient specialty. Minor spine procedures such as epidural injections and rhizotomy absolutely can be completed in the most cost-effective venue for patients without significant risk. In my practice, only very healthy patients could be eligible for outpatient spine surgery other than minor procedures. These patients are also usually on the younger spectrum of age range.
Furthermore, only very minor procedures such as single-level discectomy or laminectomy are potential procedures to perform at an ASC. The gray area lies in cervical and lumbar fusions. Most all practitioners at the Texas Back Institute feel that the potential risks associated with single level fusions in either the cervical or lumbar region are unacceptable at an ASC compared to inpatient care.
First and foremost, recommended parenteral antibiotic treatment would be interrupted with outpatient surgery, and in situations where there is a metallic implant, this poses an avoidable risk, albeit a low risk. Other concerns for performing these procedures at an outpatient facility would be having adequate equipment, experienced operating room personnel and acceptable postoperative care.
Furthermore, I believe some surgeries, such as a cervical fusion that have specific types of potential complications, which may require ICU care should be performed in the inpatient setting. The balance between cost effectiveness and what is in the patient's best interest should always guide our decision making in regard to performing procedures at an outpatient facility.
Christian Zimmerman, MD, Neurosurgeon, Idaho Neurological Institute, Boise: Personally, recent data and negative media coverage about PODs and the extrapolated parallels to outpatient surgery centers, has been a long term deterrent to this type of surgical care.
Kenneth Pettine, MD, Spine Surgeon, The Spine Institute, Johnstown, Colo.: Yes, we perform surgery in an outpatient setting. I believe this is a vitally important future in the spine industry to provide quality care at lower costs. Outpatient spine surgery is definitely the future. I would encourage everyone to visit the website for Society of Ambulatory Spine Surgery whose goal is to move at least 50 percent of all spine surgeries to an outpatient setting. Spine surgery can be performed with safety and efficacy in an outpatient center.
Erik Spayde, MD, Orthopedic Spine Surgeon, Los Robles Hospital & Medical Center, Thousand Oaks, Calif.: A significant portion of my procedures are performed in the outpatient setting. With minimally invasive procedures, patients are having less pain postoperatively and an earlier return to full mobility.
Robert Watkins Jr., MD, Co-Director of Marina Spine Center, Marina Del Rey (Calif.) Hospital: No, because the hospital where I perform surgery provides me with the efficiency, the quality of nursing and the best technology available to provide the best care possible for my patients.
Brian Gantwerker, MD, Spine Surgeon, The Craniospinal Center of Los Angeles: I have continued to operate in an outpatient setting, but less so. The payers do not seem to make it easier in either case, and many hospitals have made same-day discharges much easier.
Neel Anand, MD, Clinical Professor of Surgery & Director of Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: There are certain patients who are ideal for outpatient surgery, such as those who need simple microdecompressions, single-level anterior cervical fusions or disc replacements. These procedures are really suitable for outpatient settings with younger patients who have no co-morbidities and pass pre-operative assessments.
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