Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning

Basques, Bryce A.; Ferguson, Joseph; Kunze, Kyle N.; Phillips, Frank M.

doi:10.21037/jss.2019.04.14

Cited by 20 publications

(17 citation statements)

References 31 publications

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“…Because Medicare does not negotiate directly with implant manufacturers, individual hospitals with variable bargaining power are left to cover implant costs using the all-inclusive bundled Medicare payment, which was originally intended to incentivize cost efficiency. Recent innovations in surgical and medical device technologies have improved surgical protocols and enhanced minimally invasive surgical techniques, which may expedite postoperative discharge and recovery [34]. In addition, well-defined patient selection criteria for outpatient surgery, along with optimized anesthesia and postoperative pain management protocols, have helped reduce readmission risk and associated costs [35][36][37].…”

Section: Discussionmentioning

confidence: 99%

Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty

et al. 2020

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Background: Over 1 million total joint arthroplasties (TJAs) are performed every year in the United States, creating Medicare cost concerns for policy makers. The purpose of this study is to evaluate recent trends in Medicare utilization and reimbursements to hospitals/surgeons for TJAs between 2012 and 2017. Methods: We tracked annual Medicare claims and payments to TJA surgeons using publicly available Medicare databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization (per 10,000 Medicare beneficiaries), and reimbursement rates and to examine associations between county-specific variables and TJA utilization and reimbursements. Results: Between 2012 and 2017, there was an 18.9% increase in annual primary TJA volume (357,500 cases in 2012 to 425,028 cases in 2017) and a 2.0% increase in annual primary TJA per capita utilization (73.4 cases per 10,000 Medicare beneficiaries in 2012 to 74.8 in 2017). The Midwest and the South had higher utilization rates compared with the Northeast and West (P < .001). Utilization rates for primary TJA procedures also had a significant negative association with the poverty rate (P < .001). Medicare Part B payments to surgeons fell by 7.5%, equivalent to a 14.9% inflation-adjusted decline, whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively, during the study period. Conclusions: Despite increasing TJA volume and utilization, surgeon reimbursements have continued to decline, whereas hospital payments and hospital charges have increased significantly more than surgeon charges. Cost containment efforts will need to address other expenditures such as hospital costs and implant costs to better align financial risks and incentives for TJA surgeons.

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Section: Discussionmentioning

confidence: 99%

Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty

et al. 2020

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“…Over the past several years, a gradual shift has been made toward lumbar fusion approaches that are less invasive and theoretically protective of the thecal sac and nerve roots. Several authors have reported on their experiences of operative and perioperative (30-day) safety via a transforaminal lumbar interbody fusion (TLIF) approach [1][2][3][4][5][6], and more recently, studies examining the safety of outpatient lumbar fusion are on the rise [7][8][9][10][11][12][13][14][15][16]. Depending on the study, complications can be significantly under-reported.…”

Section: Introductionmentioning

confidence: 99%

Thirty-Day Outcomes From Standalone Minimally Invasive Surgery-Transforaminal Lumbar Interbody Fusion Patients in an Ambulatory Surgery Center vs. Hospital Setting

Schlesinger¹,

Krugman²,

Abbott

et al. 2020

Cureus

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We sought to evaluate differences in perioperative baseline characteristics, operative efficiency, and 30-day safety events for patients undergoing standalone minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) in a hospital versus an ambulatory surgery center (ASC). Methods Patients were retrospectively identified and sequentially enrolled from the office records of a single, community neurosurgeon. Records for the first 50 qualifying patients in the hospital and ASC cohorts were retrieved. Variables collected included: baseline demographic and health status, operative safety (intra-op complications) and efficiency (operative time, fluoroscopy time, etc.), and 30-day post-operative safety (emergency room visits, re-admission, and re-operation). Results At baseline, hospital and ASC patients were equivalent in gender distribution, BMI, and pre-operative narcotic use. Statistically significant differences were found in age and comorbidity burden (ASA status and Charleson Comorbidity Index); p < 0.0001, p = 0.0039, and p < 0.001 respectively. The only significant difference in construct type between hospital and ASC patients was the proportion of one-versus two-level fusions; all two-level fusions were performed in the hospital group. There were no differences in operative time, need for transfusions, or iatrogenic complications. There were also no differences between the groups in 30-day events of ER visits, re-admission, re-operation, or post-operative narcotic refill use. The length of stay was significantly different between the ASC and hospital settings (p < 0.0001). Conclusions As expected, ASC patients were younger and relatively healthier compared to their hospital counterparts. Thirty-day safety events of ER visits, re-admission, re-operation, and narcotic refill utilization were representative of population norms. Patients with standalone, expandable MIS-TLIF underwent efficient operative procedures and experienced minimal 30-day complications independent of their operative status. ASC patients had the added benefit of significantly reduced length of stay over their hospital counterparts. Given the equivalency of the 30-day post-operative course for both patient cohorts, a substantial reduction in economic burden is likely for the ASC patients.

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“…Moreover, in addition to ideal patients and masterful technique, advanced anesthesia and pain control protocols are necessary given the increased invasiveness that comes with lumbar fusion procedures. 56 Indeed, a new frontier of rapid recovery after lumbar fusion is to avoid general anesthesia altogether with the “awake TLIF,” which employs several key innovations including conscious sedation and long-acting local analgesia. 57 , 58 …”

Section: Resultsmentioning

confidence: 99%

Recoup From Home? Comparison of Relative Cost Savings for ACDF, Lumbar Discectomy, and Short Segment Fusion Performed in the Inpatient Versus Outpatient Setting

Mikhail

Echt

Selverian

et al. 2021

Global Spine Journal

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Study Design: Broad narrative review. Objective: To review and summarize the current literature on the cost efficacy of performing ACDF, lumbar discectomy and short segment fusions of the lumbar spine performed in the outpatient setting. Methods: A thorough review of peer- reviewed literature was performed on the relative cost-savings, as well as guidelines, outcomes, and indications for successfully implementing outpatient protocols for routine spine procedures. Results: Primary elective 1-2 level ACDF can be safely performed in most patient populations with a higher patient satisfaction rate and no significant difference in 90-day reoperations and readmission rates, and a savings of 4000 to 41 305 USD per case. Lumbar discectomy performed through minimally invasive techniques has decreased recovery times with similar patient outcomes to open procedures. Performing lumbar microdiscectomy in the outpatient setting is safe, cheaper by as much as 12 934 USD per case and has better or equivalent outcomes to their inpatient counterparts. Unlike ACDF and lumbar microdiscectomy, short segment fusions are rarely performed in ASCs. However, with the advent of minimally invasive techniques paired with improved pain control, same-day discharge after lumbar fusion has limited clinical data but appears to have potential cost-savings up to 65-70% by reducing admissions. Conclusion: Performing ACDF, lumbar discectomy and short segment fusions in the outpatient setting is a safe and effective way of reducing cost in select patient populations.

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Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning

Cited by 20 publications

References 31 publications

Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty

Hospital and Surgeon Medicare Reimbursement Trends for Total Joint Arthroplasty

Thirty-Day Outcomes From Standalone Minimally Invasive Surgery-Transforaminal Lumbar Interbody Fusion Patients in an Ambulatory Surgery Center vs. Hospital Setting

Recoup From Home? Comparison of Relative Cost Savings for ACDF, Lumbar Discectomy, and Short Segment Fusion Performed in the Inpatient Versus Outpatient Setting

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