Becker's Spine Review

9 SPINE SURGEONS Why Centers of Excellence are becoming prominent in spine By Alan Condon M ore healthcare organizations are seeking partnerships with talented spine sur- geons to become designated as a Center of Excellence, which takes an integrat- ed, multidisciplinary approach to care. Multidisciplinary spine centers can offer treatments that range from the conservative, such as pain management, physical therapy and nutritional care, to diagnostics, imaging, spine surgery and postoperative care. Hospitals, in particular, are increasingly considering Centers of Excellence. If they don't refine spine care protocols, they may stand to lose even more access to patients as payers continue to push patients to facilities that perform more efficient care at lower costs. But patients also want to have their care at Centers of Excellence, and they are becoming more sophisticated at researching and finding data on provider outcomes. "Surgeons should set up a mechanism to collect their surgical outcomes and ultimately be able to publicly display that data," according to Alok Sharan, MD, of NJ Spine and Wellness in East Brunswick, N.J. "[Patients] having all their spine care providers under one roof, in a one-stop shop, will be desirable and convenient. Patients will realize that coordination of their care will be easier if all providers are under one roof." Accreditation bodies such as the Joint Commission and DNV GL Healthcare offer certi- fications in spine surgery, and many commercial payers — such as Blue Cross Blue Shield — also designate spine programs that meet their criteria as Centers of Excellence, though benchmarks vary by insurer. e benefits of achieving a Center of Excellence designation can include increased pa- tient volumes, improved team cooperation, reduced complications, decreased costs and a considerable marketing advantage, which is critical in today's crowded and increasingly consumer-driven market. For centers pursuing these certifications, tracking data and metrics including outcomes, re- admission rates, length of stay and cost per case is critical. Internal standards such as tangi- ble planning, implementation, monitoring and measurement are key to achieving success. Hospitals may view Centers of Excellence as a strategy to maintain and attract more spine procedures that are rapidly migrating to the outpatient setting, but ASCs are also seeking Center of Excellence designations and direct-to-employer contracting. Earlier this year, Premier Spine Care in Overland Park, Kan., became the first dedicated ASC for spine care to join Carrum Health's growing Center of Excellence network, where bundled payments play a key role in the drive to reduce costs and improve access to care. Payers will increasingly look to forge Center of Excellence relationships to provide quality, cost-effective solutions for spine care with fair contracted rates for patients, providers and payers, according to Robert Bray Jr., MD, of DISC Sports & Spine Center in Newport Beach, Calif. "As these relationships develop, you will find great satisfaction working as a partner with payers to do what we do best: Deliver well thought-out, quality care," Dr. Bray said. "is is work that requires complete commitment to data-driven results and time spent to develop payer relationships. Find a champion that will lead this within your group and rally behind that effort." Ultimately, spine Centers of Excellence champion a commitment to high-quality, efficient care, which is attractive to payers, physicians, and most important, patients. n • In patients undergoing hemorrhoidectomy, a total of 266 mg (20 mL ) of EXPAREL was diluted with 10 mL of saline, for a total of 30 mL, divided into six 5 mL aliquots, injected by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers to produce a field block. Local Analgesia via Infiltration Dosing in Pediatric Patients The recommended dose of EXPAREL for single-dose infiltration in pediatric patients, aged 6 to less than 17 years, is 4 mg/kg (up to a maximum of 266 mg), and is based upon two studies of pediatric patients undergoing either spine surgery or cardiac surgery. Regional Analgesia via Interscalene Brachial Plexus Nerve Block Dosing in Adults The recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults is 133 mg (10 mL), and is based upon one study of patients undergoing either total shoulder arthroplasty or rotator cuff repair. Compatibility Considerations Admixing EXPAREL with drugs other than bupivacaine HCl prior to administration is not recommended. • Non-bupivacaine based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. • Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. • When a topical antiseptic such as povidone iodine (e.g., Betadine ® ) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution. Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL. Non-Interchangeability with Other Formulations of Bupivacaine Different formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa. Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug's functional properties relative to those of the unencapsulated or nonlipid-associated drug. In addition, different liposomal or lipid-complexed products with a common active ingredient may vary from one another in the chemical composition and physical form of the lipid component. Such differences may affect functional properties of these drug products. Do not substitute. CLINICAL PHARMACOLOGY Pharmacokinetics Administration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours after local infiltration and 120 hours after interscalene brachial plexus nerve block. In general, peripheral nerve blocks have shown systemic plasma levels of bupivacaine for extended duration when compared to local infiltration. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy. PATIENT COUNSELING Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue. Pacira Pharmaceuticals, Inc. San Diego, CA 92121 USA Patent Numbers: 6,132,766 5,891,467 5,766,627 8,182,835 Trademark of Pacira Pharmaceuticals, Inc. For additional information call 1-855-RX-EXPAREL (1-855-793-9727) Rx only March 2021

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