Issue link: https://beckershealthcare.uberflip.com/i/1489874
16 THOUGHT LEADERSHIP Cases migrating rapidly to ASCs, but hospitals will always be 'integral to spine surgery' By Alan Condon C MS, commercial payers and providers continue to push surgical procedures to outpatient settings, but many spine surgeons agree that hospitals will remain critical for the specialty. irteen spine surgeons from health systems and private practices across the country share their thoughts on the future of spine care at hospitals and ASCs. Editor's note: Responses were lightly edited for clarity and length. Question: What does the future of spine surgery look like in the inpatient setting? Barrett Woods, MD. Rothman Orthopaedic Institute (Philadelphia): ere is a significant push to transition most surgical services away from inpatient facilities to lower cost outpatient centers. is pressure is being exerted on providers from many different sides, including payers, patients, practices and hospital systems. As reimbursement declines and margins become razor thin, providing care in lower cost outpatient facilities seems to be a reasonable evolution. With advancements in minimally invasive techniques, perioperative anesthesia and postoperative pain protocols, a vast array of spine surgeries can and are being performed in the outpatient setting daily. is trend will continue. e concern for most surgeons is patients developing catastrophic perioperative complications while home and not within the hospital where immediate intervention can be performed. Strict adherence to exclusion criteria, perioperative optimization and evaluation of a patient's social situation are critical to successfully perform spine surgery in this setting. Jeremy Smith, MD. Hoag Orthopedic Institute (Irvine, Calif.): In the last 10 years, we have seen larger surgeries transition to the outpatient setting and we anticipate this trend will continue. Minimally invasive spine surgeries will continue to gain popularity and replace many traditional methods. For patients who require major reconstructive or revision surgeries, there will still be a need for inpatient stays and the multidisciplinary care it provides. However, reconstructive surgery will be performed with greater precision, leading to shorter stays and quicker recoveries from these procedures. I believe spine surgeons over the next 10 years will perform most of their surgeries in the outpatient setting and this will help optimize value-based care. Colin Haines, MD. Virginia Spine Institute (Reston): e future is moving to a more minimally invasive approach. Smaller incisions and less muscle disruption can achieve the same goals that previously required larger operations. With the technology at hand, we can achieve the same results but with less collateral damage to the body, so better outcomes on a faster timeline. As a byproduct of the minimally invasive approach, the surgeries do not oen require the same length of stay that they previously did. However, the reality is that not all surgeries are outpatient. Spinal deformity, complex revision surgeries and tumor/trauma are not appropriate for the outpatient setting. In the hospital setting, early activity protocols are critical. At our institution, we have been at the forefront of expedited recovery while still in the hospital setting, so-called enhanced recovery aer surgery protocols. As part of this, we can provide pain control without IV medications using a multimodal approach, including oral narcotics, non- narcotic medications, ambulation from the post-op stretcher to the bed, early catheter removal and intensive physical therapy. e result is better pain control, quicker hospital stays, fewer inpatient rehabilitation stays and better patient outcomes. Although the trend is towards surgery in ASCs, I believe the hospital will always be integral to spinal surgical care. However, for inpatient care to be optimized, it needs to mimic many of the aforementioned benefits that are achieved in the outpatient setting. Noam Stadlan, MD. NorthShore Neurological Institute and NorthShore Spine Center (Evanston and Skokie, Ill.): e current trend in spine surgery is shorter, less- invasive surgeries. ere also is pressure from insurance carriers — transmitted via hospitals — to classify patients as "outpatients" as much as possible. e result is that inpatient censuses will continue to drop. ere will be three groups of inpatients: 1. ose who have undergone surgeries which are typically outpatient, but are too medically ill to leave (almost always from pre-existing morbidities) 2. ose who have undergone larger surgeries that are not appropriate to be classified as outpatient. 3. ose who require either neurological monitoring or pain management for an extended period of time. In other words, the inpatient trend will continue towards patients being older and sicker, and having undergone large, complex surgeries. Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: e significant trend of migrating degenerative spine surgeries to the ASC setting will undoubtedly continue. Lumbar laminectomies, ACDFs, and single-level lumbar fusion procedures are being regularly done at ASCs currently. is will continue to grow, much as total joint procedures have done. Awake spine surgery for laminectomies and lumbar fusions have made the postoperative recovery even faster for patients to facilitate same day return to home. e inpatient setting will be reserved for patients with complex comorbidities that make inpatient stays more necessary or patients who need more long-term monitoring. Larger cases, including multilevel fusions and spinal deformity surgeries will continue to be done in the inpatient setting for now. Overall, the complexity of care in the inpatient setting will increase as the trend towards outpatient surgeries increases. Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): e post-pandemic reality of surgical volumes has had a direct effect on inpatient admissions and resultant revenue streams to larger and medium health systems alike. Staffing shortages, occupational realignments and inexperience are another new convention. e siphon effect and inurement of the for-profit medical culture have dramatically changed risk-adjusted and under-insured patients seeking care in larger more accepting institutions. e more vulnerable usually carry a higher ASA score and require more compounded attention and substructure. Assuredly, the more complex and tedium-