Anterior cervical discectomy and fusion in the outpatient ambulatory surgery setting compared with the inpatient hospital setting: analysis of 1000 consecutive cases

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>In an era of escalating health care costs and pressure to improve efficiency and cost of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options for many surgical therapies. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed, and the frequency of its performance is rapidly increasing as the aging population grows. Although ASCs offer significant cost advantages over hospital-based surgical centers, concern over the safety of outpatient ACDF has slowed its adoption. The authors intended to 1) determine the safety of the first 1000 consecutive ACDF surgeries performed in their outpatient ASC, and 2) compare the safety of these outpatient ACDFs with that of consecutive ACDFs performed during the same time period in the hospital setting.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A total of 1000 consecutive patients who underwent ACDF in an ACS (outpatient ACDF) and 484 consecutive patients who underwent ACDF at Vanderbilt University Hospital (inpatient ACDF) from 2006 to 2013 were included in this retrospective study of patients' medical records. Data were collected on patient demographics, comorbidities, operative details, and perioperative and 90-day morbidity. Perioperative morbidity and hospital readmission were compared between the outpatient and inpatient ACDF groups.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Of the first 1000 outpatient ACDF cases performed in the authors' ASC, 629 (62.9%) were 1-level and 365 (36.5%) were 2-level ACDFs. Mean patient age was 49.5 ± 8.6, and 484 (48.4%) were males. All patients were observed postoperatively at the ASC postanesthesia care unit (PACU) for 4 hours before being discharged home. Eight patients (0.8%) were transferred from the surgery center to the hospital postoperatively (for pain control [n = 3], chest pain and electrocardiogram changes [n = 2], intraoperative CSF leak [n = 1], postoperative hematoma [n = 1], and profound postoperative weakness and surgical reexploration [n = 1]). No perioperative deaths occurred. The 30-day hospital readmission rate was 2.2%. All 90-day surgical morbidity was similar between outpatient and inpatient cohorts for both 1-level and 2-level ACDFs.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>An analysis of 1000 consecutive patients who underwent ACDF in an outpatient setting demonstrates that surgical complications occur at a low rate (1%) and can be appropriately diagnosed and managed in a 4-hour ASC PACU window. Comparison with an inpatient ACDF surgery cohort demonstrated similar results, highlighting that ACDF can be safely performed in the outpatient ambulatory surgery setting without compromising surgical safety. In an effort to decrease costs of care, surgeons can safely perform 1- and 2-level ACDFs in an ASC environment.</jats:p></jats:sec>

Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs. Hospital Settings

“…Similar levels of improvement have already been reported for 1and 2-level ACDF in an ASC compared to the hospital. 31 The surgery and anesthesia times in this study are comparable to those reported in other outpatient cervical surgery studies. 15,16,19 As in most studies of outpatient cervical surgery, very few patients experienced AEs, needed to be readmitted, or underwent secondary surgery.…”

“…1,4 Surgeons have analyzed spinal surgeries performed in patient cohorts ranging in size from less than 100 to over 1000 patients. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] Furthermore, the comparative safety and effectiveness of spine surgery performed on an outpatient versus inpatient basis have been evaluated for a variety of procedures: lumbar discectomy, 21,22 lumbar decompression, 23,24 lumbar interbody fusion, 25,26 anterior cervical discectomy and fusion (ACDF), [27][28][29][30][31][32] and cervical disc arthroplasty (CDA). 33 The complexity of outpatient spine surgeries has also increased from microdiscectomy and decompression, to single-level fusion and multi-level fusion using an anterior approach.…”

Inpatient versus Outpatient Anterior Cervical Discectomy and Fusion: A Perioperative Complication Analysis of 259,414 Patients From the Healthcare Cost and Utilization Project Databases

“…The goal of this study was to further investigate this issue, using sample sizes far greater than any previously reported in the literature. 5,[8][9] The 259,414 patients examined in this study is more than 35 times greater than the previous largest study comparing inpatient versus outpatient ACDF, which involved fewer than 7,300 patients. 5 Our results indicate that in the perioperative period for fusions of 1-2 levels, outpatient ACDF was associated with fewer perioperative complications than inpatient ACDF, most prominently with regard to paraplegia, postoperative infection, respiratory complications, acute posthemorrhagic anemia, and red blood cell transfusion requirement.…”

“…[6][7] The complications of outpatient versus inpatient ACDF have been examined sparsely in the literature, with only one study using a population-based database to examine surgical safety and quality between outpatient and inpatient ACDF. 5,[8][9] The present study was performed to examine this area utilizing the Health Care Cost and Utilization Project (HCUP) databases, the largest family of populationbased databases cited in the peer-reviewed literature.…”

Safety of outpatient anterior cervical discectomy and fusion: a systematic review and meta-analysis

“…Figure 1 shows the flow diagram that reflects the search process. Among the 12 article, seven [16, 18, 21, 22, 24, 25, 27] were subsumed into the meta-analysis, and the other five [17, 19, 20, 23, 26] were included to present the complications of the outpatient surgery.

Fig. 1Flow diagram of the study selection which shows the number of citations identified, excluded and included in final analysis

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