Spine Roundtable: Outpatient Spine Surgery: Five Surgeons on Performing Cases in ASCs

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Outpatient Spine Surgery: Five Surgeons on Performing Cases in ASCs By Laura Miller Five spine surgeons discuss the opportuni- ties for performing spine surgery in out- patient ambulatory surgery centers and where they see the field headed in the future. Q: How has technology and technique develop- ment made it possible to bring spine procedures into the outpatient setting? William Tally, MD, Athens (Ga.) Orthopedic Clinic: e technology allows us to be more ef- ficient during the surgery, decreasing anesthesia time and allowing for less tissue damage. All of this makes the patients' early recovery smoother. ese factors make patients more functional within 24 to 48 hours allowing us to perform the same complexity of proce- dures in the outpatient setting. e minimally invasive proce- dures are more complex, but they are more efficient and less destructive. Ashish Sahai, MD, Spine & Orthopedic Center, Deer- field Beach, Fla.: e OLLIF is ideal because there is less tissue disruption, operative time and bony resection. It can also be combined with other minimally invasive techniques as neces- sary, serving a dual purpose. Gerald Schell, MD, Saginaw (Mich.) Valley Neurosurgery: e OLLIF is done with very little tis- sue damage. e stan- dard surgeries or interbody fusions require a large incision, removal of major facet joints, creating scarring around the nerves. is iatrogenic damage makes it difficult to send the pa- tient home that day. e OLLIF procedure is a lateral interbody technique that doesn't re- quire the removal of any bone. ere is very little trauma to any tissue and the work performed di- rectly addresses the patient's pathology. Q: What are the advantages to performing spinal cases as outpatient procedures? Randolph Bishop, MD, Neuro- logical Institute of Savannah (Ga.): e advantages of using an out- patient center for the performance of spine sur- gery yields similar advantages to what has been demonstrated in other subspecialties. An outpa- tient surgery center provides for a more personal level of patient care which is a strong positive for both patients and surgeons. e care delivered is much more specialized and the cen- ter can be more focused on a specific spe- cialty which leads to a more efficient and effective delivery of service. Bobby Bhatti, MD, Rockdale Orthopedic Center, Conyers, Ga.: ere are also ad- vantages to the ASC setting for surgeons. Our ASC was critical in attract- ing patients to our practice. Patients pre- fer the ASC setting and it's more efficient for both patients and physicians. Given the lower risk of infection, low- er need for narcotic pain relief post-procedure, and higher pa- tient satisfaction ratings, I try to use the ASC for as many pa- tients as medically appropriate. WT: Our patient satisfaction rates are much higher in the surgery center. Overall, it is a better experience for patients as it is less daunting than the large Outpatient Spine Surgery 2 46 Spine Roundtable geons in private practice. Furthermore, employers and cash paying patients are starting to avoid insurance companies altogether and come directly to the surgeon. If you are an efficient surgeon operating in an ASC, you can provide tremendous value to these stakeholders. The value proposition is only going to become more important in the changing healthcare land- scape. Q: What differences are there for surgeons when they first start doing cases at the ASC as opposed to the hospital? AS: Surgery centers are usually run differently than hospitals. Typically there are fewer resources available and there is emphasis on only using what is needed for the surgery. It is also important to make sure there is adequate follow-up with patients postoperatively. Finally, it is important in the ASC to be comfortable and familiar with equipment and instrumentation provided by the facility. Q: Many surgeons are considering the adoption of new spine surgeries and minimally invasive techniques into their practices. Do you have any tips for them? GS: As surgeons start to move minimally invasive spine surgery to the outpatient setting, there should be adequate training, including case ob- servations, with experienced surgeons. During the first few procedures in the ASC, surgeons should have access to teaching physician to answer any questions that may develop while observing the patient. Patient selection is a key factor in successful outpatient surgery. Knowing which patients are candidates, and more importantly which patients are not, is critical in the outpatient setting. Having been a busy spine surgeon for the last 25 years and now doing these procedures for about 10 years, in my mind the absolutely best way for spine surgery to be done is with minimally invasive techniques in the outpatient setting. Performing cases at the ASC with the right technique and the right context is the future of spine surgery in our country. WT: Patients needed to be educated on the level of pain they will experience, what they are expected to do postoperatively, and what is within the range of normal with regards to pain. Sometimes patients think that because their surgery is performed in the outpatient setting, their pain levels should be lower, and they panic. When patients know what to expect, it greatly reduces postoperative prob- lems with pain. Let them know they can still contact your office after surgery with any questions or worries — this reduces the urge to head straight to the ED if they become concerned about their pain levels after returning home. BB: Surgeons and patients have to feel comfortable in this setting. When first starting, it may be helpful to keep patients in the hospital for one night to assess how well they do. Additionally, patients need to be educated about the timeline for discharge. Either speak with them directly, or have a staff mem- ber from the office educate them. Provide patients with educational materials about what to expect from out- patient spine surgery and be available to answer their questions and con- cerns. The outcomes will follow; patients will be discharged earlier from hospital and the transition to the ASC will be successful. Q: Do you think more spine surgeons will begin performing cas- es in the ASC going forward? RB: The performance of most routine spinal surgeries will be performed an outpatient setting in the future. Surgeons that do not prepare for this will be unable to compete effectively against those that do and these same sur- geons may in fact be viewed as "less capable" as a result. GS: Right now, it seems like the drivers of cost in the hospital costs are procedures, including spine surgery. I am currently able to do 80 percent my major spinal surgeries in an ASC. If 80 percent of all spine surgeries could be done in outpatient surgery centers, I would think this could be huge the country which is currently drowning under the cost of medical care. The timing is perfect for this type of procedure to start the precedent of outpa- tient spine surgery. Q: Where do you see the most opportunity for growth in the out- patient spine surgery center setting in the future? AS: Endoscopic spine surgery is become an interesting avenue that is being reevaluated after falling out of favor. Simple decompressions and microd- iscectomies are moving to the outpatient departments at hospitals, so ASC setting is the next logical choice. One-level ACDF procedures are being routinely performed in the outpatient setting, but the biggest opportunity lumbar fusions in non-complex patients. WT: As more surgeons are trained in this setting, we are going to see a higher volume of both cervical and lumbar procedures performed in the outpatient setting. A bigger opportunity in the outpatient setting are lumbar proce- dures. When surgical techniques can be streamlined enough to reduce anes- thesia time, and instrumentation is developed that can reduce the number steps in a procedure (like OLLIF), we will facilitate the move of spinal fusions to the outpatient setting. n "The advantages of using an outpatient center for the performance of spine surgery yields similar advantag- es to what has been demonstrated in other subspecial- ties. An outpatient surgery center provides for a more personal level of patient care which is a strong positive for both patients and surgeons." — Dr. Randolph Bishop

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