Quality analysis of anterior cervical discectomy and fusion in the outpatient versus inpatient setting: analysis of 7288 patients from the NSQIP database

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>In an era of escalating health care cost and universal pressure of improving 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 is rapidly increasing with an expanding aging population. While ASCs offer cost advantages for ACDF, there is a scarcity of evidence that ASCs allow for equivalent quality and thus superior health care value. Therefore, the authors analyzed a nationwide, prospective quality improvement registry (National Surgical Quality Improvement Program [NSQIP]) to compare the quality of ACDF surgery performed in the outpatient ASC versus the inpatient hospital setting.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Patients undergoing ACDF (2005-2011) were identified from the NSQIP database based on the primary Current Procedural Terminology codes. Patients were divided into 2 cohorts (outpatient vs inpatient) based on the acute care setting documented in the NSQIP database. All 30-day surgical morbidity and mortality rates were compared between the 2 groups. Propensity score matching and multivariate logistic regression analysis were used to adjust for confounding factors and to identify the independent association of outpatient ACDF with perioperative outcomes and morbidity.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 7288 ACDF cases were identified (inpatient = 6120, outpatient = 1168). Unadjusted rates of major morbidity (0.94% vs 4.5%, p &lt; 0.001) and return to the operating room (OR) within 30 days (0.3% vs 2.0%, p &lt; 0.001) were significantly lower in outpatient versus inpatient ACDF. After propensity matching 1442 cases (inpatient = 650, outpatient = 792) based on baseline 32 covariates, rates of major morbidity (1.4% vs 3.1%, p = 0.03), and return to the OR (0.34% vs 1.4%, p = 0.04) remained significantly lower after outpatient ACDF. Adjusted comparison using multivariate logistic regression demonstrated that ACDF performed in the outpatient setting had 58% lower odds of having a major morbidity and 80% lower odds of return to the OR within 30 days.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>An analysis of a nationwide, prospective quality improvement registry representing more than 250 hospitals demonstrates that 1- to 2-level ACDF can be safely performed in the outpatient ambulatory surgery setting in patients who are appropriate candidates. In an effort to decrease cost of care, surgeons can safely consider performing ACDF in an ASC environment.</jats:p></jats:sec>

Definitional Differences of ‘Outpatient’ Versus ‘Inpatient’ THA and TKA Can Affect Study Outcomes

“…Despite the definitional differences, certain past orthopaedic data set studies relied on the nebulous ''inpatient''/ ''outpatient'' NSQIP variable in their analysis as opposed to LOS[0/LOS = 0 [32,35,41,50]. When a comparison was done using admission status as a predictor of adverse events after THA, an ''inpatient'' assignment in comparison to an ''outpatient'' assignment was found to be associated with an increased risk of any adverse event, SAE, and readmission (Fig.…”

“…Multiple studies in orthopaedics have used NSQIP, a large national database that provides an ''outpatient'' status variable, to study outpatient procedures without determining what, exactly, ''outpatient'' means in NSQIP [32,35,41]. Under current regulations in the United States, patients who underwent outpatient surgery may stay one or more nights at the hospital under ''observation'' status despite being coded as an outpatient [38].…”

“…Many studies in different surgical subspecialties have used this variable to compare short-term outcomes of inpatient versus outpatient surgery [19-22, 27, 28, 33, 34, 36, 39, 42-46]. Multiple recent studies in orthopaedics have used these variables to study outpatient procedures or have included these variables in their studies as well [32,35,41,50]. However, in NSQIP, the ''inpatient'' or ''outpatient'' variable is distinct from the hospital length of stay (LOS) variable [1].…”

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

“…[1][2][3] Due to persistent and unsustainable growth in healthcare costs, with surgical care alone comprising 7% of the United States gross domestic product (GDP), cost-saving strategies such as outpatient and ambulatory surgery centers have increased in popularity, given that they cost approximately 30% less than comparable inpatient hospital procedures. [4][5] Recently, a few single-center studies using relatively small sample sizes have examined intraoperative and perioperative complications of outpatient ACDF in order to assess its safety, motivated in part by the realities of the current medical-legal climate. [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.…”

“…[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.…”