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16 SPINE SURGEONS Dr. James Chappuis on how to improve OR efficiency and deliver cost-effective spinal fusions By Alan Condon J ames Chappuis, MD, has been in private practice for over 28 years as the owner and senior orthopedic spine surgeon of Spine Center Atlanta. Dr. Chappuis specializes in revision spine procedures and has seen his practice grow to eight locations, with further facilities planned in the future. Here, Dr. Chappuis discusses how spinal fusion can become more cost-ef- fective, the key to operating room efficiency and future trends in outpatient fusion proce- dures. Note: Responses have been lightly edited for style and clarity. Question: How can spine surgeons help make spinal fusions more cost-ef- fective without sacrificing quality? How do you see spinal fusions evolv- ing in the future? Dr. James Chappuis: e most relevant way to make spinal fusions more cost-effective with- out sacrificing quality is to perform them in an outpatient surgery setting. ere is no doubt that you can save money in this type of setting. Overall, your quality can improve because you have control over what you can use, in addi- tion to the choice of who you're working with. I maintain consistency amongst my staff with the same standards of excellence for each case. If we're talking about the degenerative spine, I am performing less spinal fusion procedures than I did 15 or 20 years ago. If fusions are in- dicated, we prefer anterior lumbar interbody fusion and have performed more than 100 out- patient procedures over the past four years. Q: What device has dramatically im- proved OR efficiency in your practice? JC: Consistent, first-class OR staff. I have the same first assistant, the same scrub tech, the same circulating nurse for every case. is significantly improves efficiency and decreas- es OR time. is is generally not possible in an inpatient setting. Q: What are the most pressing issues for outpatient spinal fusions? JC: No. 1 would be postoperative pain control. For that, we use Exparel and limited narcotics for a short period of time if necessary. Q: How do you think robotics will im- pact spinal fusions in the future? JC: Robotics are very costly. It will be more difficult to perform surgery in an outpatient setting because of the cost. However, I think robotics will increase the accuracy of surgery, particularly pedicle screw instrumentation. Q: In your opinion, what is the next big trend on the horizon in spine? JC: Endoscopic spine surgery. Today, only about 5 percent of adult spine surgery in the U.S. is performed endoscopically, while 15 percent is being performed in Europe and 30 percent in South Korea. Endoscopic surgical procedures, including endoscopic fusions, are the next wave of technology, in my opinion. n Spine surgery utilization, cost in the US: 5 key findings By Laura Dyrda A n article published in Spine examines the outcomes and utilization statistics for spine surgery in both the United States and Canada from 2011 to 2015. Researchers used population-level administrative data gathered between 2011 and 2015 in Ontario, Canada, as well as data gathered between 2011 and 2014 on adults who underwent spine surgery in New York. The research- ers also compiled information about spine surgery in both countries based on previously published literature. Five key notes: 1. There are around 900,000 adults in America and 30,000 adults in Canada that undergo spine surgery per year. 2. The direct cost for inpatient hospital procedures ranges from $4,500 to $30,000 with the difference in price based on the procedure performed and location. 3. During the period studied, patients in New York were younger on average than patients in Ontario when receiv- ing decompression and fusion procedures. The average age for decompressions in Ontario was 58.8 while the aver- age age in New York was 51.3. The average age for spinal fusion was 58.1 years old in On- tario and 54.9 years old in New York. 4. The utilization of decompressions and fusions in Ontario was 6.6 procedures per 10,000 population per year, which was much lower than in New York. The data from New York showed the utilization rate was 16.5 per 10,000 population per year. 5. The gap between the two countries in elective proce- dures was large as well. The utilization of elective proce- dures in Ontario was 4.6 per 10,000 population per year, compared to 13.9 in New York. n