Outpatient anterior cervical discectomy and fusion in the ambulatory surgery center setting: safety assessment for the Medicare population

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Several studies have demonstrated that anterior cervical discectomy and fusion (ACDF) surgery in the outpatient versus hospital setting provides improved efficiency, cost-effectiveness, and patient satisfaction without a compromise in safety or outcome. Recent anecdotal reports, however, have questioned whether outpatient ACDF surgery is safe in the &gt; 65-year-old Medicare population. To date, no clinical study has assessed the safety of outpatient ACDF in an ambulatory surgery center (ASC), specifically in a Medicare population. The authors set out to analyze their 3-year experience with Medicare-enrolled patients undergoing ACDF surgery at a single ASC to determine its safety profile, perioperative care protocol, and associated outcomes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A retrospective analysis of 119 consecutive patients &gt; 65 years (Medicare-eligible) who underwent 1-, 2-, or 3-level ACDF at a single ASC from 2015 to 2018 (since Medicare payment approval) was conducted. All patients were in American Society of Anesthesiologists classes I–III. Postoperatively, patients were observed for a minimum of 4 hours in a recovery setting for the following factors: neck swelling, neurological status, ability to swallow solid food, and urination capacity. All patients received a multimodal pain management regimen prior to discharge home. Data were collected on patient demographics, comorbidities, operative details, and all perioperative and 90-day morbidity.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Complete data were available for all 119 consecutive Medicare-eligible patients, 97 (81.5%) of whom were actively enrolled in Medicare. One-, 2-, and 3-level ACDFs were performed in 103 (86.6%), 15 (12.6%), and 1 (0.8%) patients, respectively. No patients required return to the operating room for intervention within the 4-hour postanesthesia care unit observation window. No patients required transfer from the ASC to the hospital setting for further observation or intervention. Thirty-day adverse events were reported in 2.4% of cases, all of which resolved by 90 days after surgery. The incidence of 90-day hospital readmission was 1.7% (n = 2), with 1 patient (0.8%) requiring reoperation at the index level for deep infection. All-cause 90-day mortality was 0%.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>An analysis of consecutive Medicare patients (American Society of Anesthesiologists classes I–III) who underwent mostly 1-level and some 2-level ACDFs in an ASC setting demonstrates that surgical complications occur at a low rate with a safety profile similar to that reported for both inpatient ACDF and patients younger than 65 years. In an effort to reduce cost and improve efficiency of care, surgeons can safely perform ACDF in the Medicare population in an ASC environment utilizing patient selection criteria and perioperative management similar to those reported here.</jats:p></jats:sec>

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis

“…6 Large studies previously published by our group have convincingly demonstrated the safety of ambulatory ACDF given careful patient selection, meticulous surgical technique, and standardized perioperative protocols for postoperative observation and complication management. [4][5][6] While the safety of ambulatory ACDF is well established, the cost-effectiveness of ACDF in the ambulatory versus inpatient setting remains unexamined. Most cost-effectiveness studies in the literature compare ACDF to other cervical procedures (e.g.…”

“…As detailed in prior reports, this single ASC has rigorous criteria for patient selection, postoperative monitoring, and complication management. [4][5][6] Results may not be generalizable to ASCs lacking these protocols. In addition, this study excluded ASA IV or V patients and those who underwent three-level or four-level ACDF.…”

Choose Wisely: Surgical Selection of Candidates for Outpatient Anterior Cervical Surgery Based on Early Complications Among Inpatients

“…Patients could not have myelopathy, had to have surgery with the use of a structural allograft, had to have an operative time under 2 hours, had to have a small neck, and had to have an appropriate discharge environment 33 . Others have since modified these selection criteria; however, a lack of consensus remains 6,[34][35][36] . Based on this series, our results suggest that outpatient surgery should target younger patients who are nonsmokers without anxiety, COPD, hypertension, gastroesophageal reflux, chronic kidney disease, a cerebrovascular accident history, or asthma and have an ASA score of <3.…”

233. Ambulatory single-level posterior cervical foraminotomy for cervical radiculopathy: a propensity matched analysis of complication rates

“…The results of this study are consistent with those reported in the literature. Several studies have shown equal or decreased complication rates in various ambulatory cervical spine procedures, including anterior cervical discectomy and fusion 10,18,29 and posterior cervical decompression. 8,30 However, it is worth noting that the aforementioned studies are not without limitations.…”